Meta-analysis of drug-related deaths soon after release from prison

First-time offenders for recreational ketamine use under a new penalty system in Taiwan: incidence, recidivism and mortality in national cohorts from 2009 to 2017

BACKGROUND AND AIMS

Ketamine has become a new recreational drug of choice among young people in parts of Asia. Using national databases in Taiwan, this study aimed to (1) examine the yearly trend in the ketamine offence rate over time; (2) estimate the 3-year risk of drug-related re-offence and its correlates among the first-time offenders; and (3) estimate the 3-year standardized mortality ratio (SMR) among the first-time offenders.

DESIGN, SETTING AND PARTICIPANTS

Retrospective cohort studies of offenders for recreational ketamine use in a penalty system initiated in 2009. Offenders for recreational ketamine use were identified from the Administrative Penalty System for Schedule III/IV Substances database from 2009 to 2017, and the re-offence rate and mortality among first-time offenders were assessed via record-linkage within the database as well as with both the criminal drug offence database and the national mortality database. The cohort from 2009 to 2016 (n = 39 178) was used for the recidivism analysis and the cohort from 2009 to 2013 (n = 25 357) was used for the 3-year SMR analysis.

MEASUREMENTS

Recidivism was estimated using survival analysis of the event as re-arrest for using ketamine, more serious illicit drugs (Schedules I/II), or any illicit drugs (ketamine or Schedules I/II). SMRs were estimated for overall and cause-specific death within 3 years after the first offence for ketamine use.

FINDINGS

The age-standardized rates for both prevalent (1.38 per 1000) and first-time offenders (0.65 per 1000) peaked in 2013 and then decreased steadily. The 3-year risk of re-offence was 33.85% [95% confidence interval (CI) = 33.23-34.47%) for ketamine use and 39.52% (95% CI = 39.00-40.04%) for any illicit drug use. These first-time offenders had an SMR of 4.9 (95% CI = 4.3-5.4) for overall mortality, 2.1 (95% CI = 1.6-2.7) for natural deaths and 7.6 (95% CI = 6.7-8.6) for unnatural deaths.

CONCLUSIONS

Recreational ketamine use in Taiwan appears to lead not only to high risk for drug-related re-offence but also to excess mortality.

Who stays in medication treatment for opioid use disorder? A national study of outpatient specialty treatment settings

BACKGROUND

Maintenance treatments with medications for opioid use disorder (MOUD) are highly effective at reducing overdose risk while patients remain in care. However, few patients initiate medication and retention remains a critical challenge across settings. Much remains to be learned about individual and structural factors that influence successful retention, especially among populations dispensed MOUD in outpatient settings.

METHODS

We examined individual and structural characteristics associated with MOUD treatment retention among a national sample of adults seeking MOUD treatment in outpatient substance use treatment settings using the 2017 Treatment Episode Dataset-Discharges (TEDS-D). The study assessed predictors of retention in MOUD using multivariate logistic regression and accelerated time failure models.

RESULTS

Of 130,300 episodes of MOUD treatment in outpatient settings, 36% involved a duration of care greater than six months. The strongest risk factors for treatment discontinuation by six months included being of younger age, ages 18-29 ((OR):0.52 [95%CI:0.50-0.54]) or 30-39 (OR:0.57 [95%CI:0.55-0.59); experiencing homelessness (OR: 0.70 [95%CI:0.66-0.73]); co-using methamphetamine (OR:0.48 [95%CI:0.45-0.51]); and being referred to treatment by a criminal justice source (OR:0.55 [95%CI:0.52-0.59) or by a school, employer, or community source (OR:0.71 [95%CI:0.66-0.76).

CONCLUSIONS

Improving retention in treatment is a pivotal stage in the OUD cascade of care and is critical to reducing overdose deaths. Efforts should prioritize interventions to improve retention among patients who are both prescribed and dispended MOUD, especially youth, people experiencing homelessness, polysubstance users, and people referred to care by the justice system who have especially short stays in care.

The state of harm reduction in prisons in 30 European countries with a focus on people who inject drugs and infectious diseases

BACKGROUND

People who inject drugs are often imprisoned, which is associated with increased levels of health risks including overdose and infectious diseases transmission, affecting not only people in prison but also the communities to which they return. This paper aims to give an up-to-date overview on availability, coverage and policy framework of prison-based harm reduction interventions in Europe.

METHODS

Available data on selected harm reduction responses in prisons were compiled from international standardised data sources and combined with a questionnaire survey among 30 National Focal Points of the European Monitoring Centre for Drugs and Drug Addiction to determine the level of availability, estimated coverage and policy framework of the interventions.

RESULTS

Information about responses to health harms in prisons is limited and heterogeneous. Cross-country comparability is hampered by diverging national data collection methods. Opioid substitution treatment (OST) is available in 29 countries, but coverage remains low (below 30% of people in need) in half of the responding countries. Needle and syringe programmes, lubricant distribution, counselling on safer injecting and tattooing/piercing are scarcely available. Testing for infectious diseases is offered but mostly upon prison entry, and uptake remains low in about half of the countries. While treatment of infections is mostly available and coverage is high for human immunodeficiency virus (HIV) and tuberculosis, hepatitis B and C treatment are less often provided. Health education as well as condom distribution is usually available, but provision remains low in nearly half of the countries. Post-release linkage to addiction care as well as to treatment of infections is available in a majority of countries, but implementation is often partial. Interventions recommended to be provided upon release, such as OST initiation, take-home naloxone and testing of infections, are rarely provided. While 21 countries address harm reduction in prison in national strategic documents, upon-release interventions appear only in 12.

CONCLUSIONS

Availability and coverage of harm reduction interventions in European prisons are limited, compared to the community. There is a gap between international recommendations and 'on-paper' availability of interventions and their actual implementation. Scaling up harm reduction in prison and throughcare can achieve important individual and public-health benefits.

New hepatitis C virus infection, re-infection and associated risk behaviour in male Irish prisoners: a cohort study, 2019

BACKGROUND

Prisoners are recognised as a high-risk population and prisons as high-risk locations for the transmission of hepatitis c virus (HCV) infection. Injecting drug use (IDU) is the main driver of HCV infection in prisoners and harm reduction services are often suboptimal in prison settings. HCV prevalence and incident data in prisoners is incomplete which impacts the public health opportunity that incarceration provides in identifying, treating and preventing HCV infection. The aim of this study is to identify new HCV infection and associated risk factors in an Irish male prison.

METHODS

We conducted a follow up (18-month) cohort study on prisoners who had previously tested negative, self-cleared or had been successfully treated for HCV infection. We conducted the study in a male medium security prison located in Dublin Ireland (Mountjoy Prison) using HCV serology, a review of medical records and a researcher-administered questionnaire.

RESULTS

99 prisoners with a mean age of 33.2 yrs. participated in the study and 82(82.8%) completed a research-administered questionnaire. Over half (51%) had a history of drug use from a young age (14.8 yrs.), 49.9% a history of heroin use and 39% a history of IDU. The prevalence of HIV and hepatitis B virus core antibody was 3% and HCV antibody was 22.2%. No new HCV infections were identified in those who had never been infected (n = 77), had self-cleared (n = 9) or achieved sustained virological response (n = 12). Small numbers of prisoners continued to engage in risk-behaviour including, IDU both in the prison (n = 2) and the community (n = 3), sharing syringes (n = 1) and drug taking paraphernalia (n = 6) and receiving non-sterile tattoos (n = 3).

CONCLUSION

Despite the high numbers of Irish prisoners with a history of IDU and HCV infection, new HCV infection is low or non-existent in this population. Small numbers of prisoners continue to engage in risk behaviour and larger studies are required to further understand HCV transmission in this cohort in an Irish and international context.

Linking criminal justice-involved individuals to HIV, Hepatitis C, and opioid use disorder prevention and treatment services upon release to the community: Progress, gaps, and future directions

Improving HIV and Hepatitis C Virus (HCV) management among people involved in the criminal justice (CJ) system who use drugs, in particular those with opioid use disorder (OUD), requires effective approaches to screening, linkage, and adherence to integrated prevention and treatment services across correctional and community agencies and providers. This manuscript reviews the literature to explore gaps in HIV, Hepatitis C, and OUD prevention, treatment, and delivery cascades of care for persons involved in the CJ system. Specifically, we compare two models of linkage to prevention and treatment services: Peer/Patient Navigation (PN) wherein the PN links CJ-involved individuals to community-based infectious disease (ID) and substance use prevention and treatment services, and Mobile Health Units (MHU) wherein individuals are linked to a MHU within their community that provides integrated ID and substance use prevention and treatment services. The most notable finding is a gap in the literature, with few to no comparisons of models linking individuals recently released from the CJ system to integrated HIV, Hepatitis C, and OUD prevention and treatment and other harm reduction services. Further, few published studies address the geographical distinctions that affect service implementation and their effects on these substance use, ID and harm reduction care cascades. This manuscript makes specific recommendations to fill this gap through a detailed evaluation of PN and MHU linkage models to co-located and integrated HIV, Hepatitis C, and OUD prevention and treatment services across different communities within the U.S.

Characteristics and risk of incarceration among "hard-to-reach" people who use drugs: A five-year prospective cohort study combining self-reports and registry data

BACKGROUND

Incarcerations are associated with an increased risk of morbidity and mortality among people who use drugs (PWUD). In a sample of 884 PWUD, we examine and estimate the risk of incarcerations (i.e., number, duration, and most serious offense).

METHODS

In this prospective cohort study, PWUD were recruited from street- and low-threshold services in seven Norwegian cities in 2013 (Sept-Nov), and followed through the Correctional Service Registry until 20.12.2018. The risk of incarceration during follow-up was examined with multivariable logistic (no incarceration vs. at least one) and multinomial regression models ("no incarcerations", vs. "1″, "≥2″), while accounting for gender, age, homelessness/shelter use, opioid substitution treatment, illegal income sources, injecting behaviours, previous incarcerations, and recruitment city.

RESULTS

During follow-up, there were in total 662 incarceration episodes, and 44.7% of the participants were incarcerated at least once. Overall, 37.5% of those incarcerated had at least one episode due to a drug offense. The average incarceration duration was 65.2 days with 3.5% of the episodes lasting ≥one year. Gender (male), homelessness/shelter use, illegal income sources, injecting stimulants, and previous incarcerations increased the odds of incarceration, while older age decreased the odds. Gender (male), younger age, self-reported theft or theft and dealing, injecting stimulants or heroin and stimulants and previous incarcerations increased the risk of multiple incarcerations.

CONCLUSION

In a five-year prospective study of PWUD, incarcerations were common, and short-term sentences and recidivism were the norm. This is of concern as incarcerations add to an already elevated morbidity and mortality risk in this population.

Stayin' Alive Through Health Education in a Correctional Setting

Individuals who are incarcerated are disproportionately affected by chronic disease, mental health concerns, and substance use, compared to the general population. Despite the need to improve health in individuals who are incarcerated, the delivery of quality health care, including health education, often meets with challenges. Quality health education lays a foundation for improved health, and is one strategy nurses can use to improve the health of incarcerated individuals. To address this pressing health need, students in a community health nursing course at the University of Illinois at Chicago provided health education to men finishing their prison sentences at an adult transition center. Verbal and written statements from the men and the students indicate that the educational offering was a positive experience. One man's attendance at a health education class had a life-changing impact on another man at the center.

Explaining the Differences in Opioid Overdose Deaths between Scotland and England/Wales: Implications for European Opioid Policies

BACKGROUNDS

Between 2009 and 2018, the number of opioid-related deaths (ORDs) in Scotland showed a dramatic increase, whereas in England and Wales, a much lower increase in ORD was seen. This regional difference is remarkable, and the situation in Scotland is worrisome. Therefore, it is important to identify the drivers of ORD in Scotland.

METHODS

A systematic literature review according to PRISMA guidelines was conducted to identify peer-reviewed studies about key drivers for the observed differences in ORDs between Scotland and England/Wales. In addition, non-peer-reviewed reports on nationwide statistical data were retrieved via Google and Google Scholar and analysed to quantify differences in ORD drivers between Scotland and England/Wales.

RESULTS

The systematic review identified some important drivers of ORD, but none of these studies provided direct or indirect comparisons of ORD drivers in Scotland and England/Wales. However, the reports with nationwide statistical data showed important differences in ORD drivers between Scotland and England/Wales, including a higher prevalence of people using opioids in a problematic way (PUOP), more polydrug use in people using drugs in a problematic way (PUDP), a higher age of PUDP, and lower treatment coverage and efficacy of PUDP in Scotland compared to England/Wales, but no regional differences in injecting drug use, incarceration/prison release without treatment, and social deprivation in PUDP.

CONCLUSION

It is concluded that the opioid crisis in Scotland is best explained by a combination of drivers, consisting of a higher population involvement in (problematic) opioid use (notably methadone), relatively more polydrug use (notably benzodiazepines and gabapentinoids), a steeper ageing of the PUOP population in the past 2 decades, and lower treatment coverage and efficacy in Scotland compared to England/Wales. The findings have important consequences for strategies to handle the opioid crisis in Scotland.

Associations Between Parole, Probation, Arrest, and Self-reported Suicide Attempts

This study estimated the associations between three categories of recent community criminal justice (CJ) involvement (arrest, parole, and probation) and suicide attempts, while accounting for how the categories overlap. Participants included adults aged ≥ 18 who completed the 2008-2014 National Surveys on Drug Use and Health. The outcome was self-reported suicide attempt(s) in the past 12 months (in the community or while incarcerated). Community CJ involvement included parole, probation, and/or arrest(s) during the past 12 months. Controls with no recent CJ involvement were matched to those with any recent involvement on demographics and education. We calculated the 12-month prevalence of suicide attempts for those reporting recent parole, probation, and arrest, including their overlaps. Logistic regression models estimated the associations between each category of recent CJ involvement and suicide attempts, controlling for their overlapping and covariates. There were 15,462 participants with recent community CJ involvement and 248,520 matched controls. The 12-month prevalence of suicide attempts was 3.2% for those with recent parole, 2.7% for probation, and 3.3% for arrest, which were all greater than the matched controls (1.0%, p < 0.001 for each). After controlling for overlapping and covariates, arrest was associated with suicide attempts (RR = 1.80, 99% CI 1.47-2.19), but neither parole (RR = 1.00, 99% CI 0.64-1.56) nor probation (RR = 0.81, 99% CI 0.61-1.08) were. Adults with recent arrest had higher risk of suicide attempts than those with parole, probation, or matched controls with no CJ involvement. Recent arrest may signify elevated risk and warrant increased screening and intervention.

Utilization of substance use treatment among criminal justice-involved individuals in the United States

Over six million individuals are involved with the criminal justice system in the United States, of which a large proportion report extensive substance use. We examined the extent to which criminal justice-involvement affects substance use treatment utilization among participants from one of the largest annual surveys on substance use in the U.S., the National Survey on Drug Use and Health (NSDUH). Multivariable logistic regression analyses indicated that criminal justice involvement was significantly associated with receiving substance use treatment in the past year (AOR 8.00, 95% CI: 6.23-10.27, p < 0.001). However, those with criminal justice histories continue to face barriers to treatment. Among individuals ages 12 and older who reported past year criminal justice involvement and met criteria for a substance use disorder, 18.9% reported receiving past year substance use treatment. After controlling for key demographic and drug use characteristics in a multivariable logistic regression model, Black criminal justice involved Americans were somewhat less likely to report receiving substance use treatment in the past year compared to White criminal justice involved Americans, although the association was not significant (AOR 0.87, 95% CI 0.58-1.29, p = 0.481). Treatment programs targeted to increase minority engagement and address persistent barriers to substance use treatment may be valuable for curbing substance use and recidivism among criminal justice-involved individuals.

Periods of altered risk for non-fatal drug overdose: a self-controlled case series

BACKGROUND

Being recently released from prison or discharged from hospital, or being dispensed opioids, benzodiazepines, or antipsychotics have been associated with an increased risk of fatal drug overdose. This study aimed to examine the association between these periods and non-fatal drug overdose using a within-person design.

METHODS

In this self-controlled case series, we used data from the provincial health insurance client roster to identify a 20% random sample of residents (aged ≥10 years) in British Columbia, Canada between Jan 1, 2015, and Dec 31, 2017 (n=921 346). Individuals aged younger than 10 years as of Jan 1, 2015, or who did not have their sex recorded in the client roster were excluded. We used linked provincial health and correctional records to identify a cohort of individuals who had a non-fatal overdose resulting in medical care during this time period, and key exposures, including periods of incarceration, admission to hospital, emergency department care, and supply of medications for opioid use disorder (MOUD), opioids for pain (unrelated to MOUD), benzodiazepines, and antipsychotics. Using a self-controlled case series, we examined the association between the time periods during and after each of these exposures and the incidence of non-fatal overdose with case-only, conditional Poisson regression analysis. Sensitivity analyses included recurrent overdoses and pre-exposure risk periods.

FINDINGS

We identified 4149 individuals who had a non-fatal overdose in 2015-17. Compared with unexposed periods (ie, all follow-up time that was not part of a designated risk period for each exposure), the incidence of non-fatal overdose was higher on the day of admission to prison (adjusted incidence rate ratio [aIRR] 2·76 [95% CI 1·51-5·04]), at 1-2 weeks (2·92 [2·37-3·61]), and 3-4 weeks (1·34 [1·01-1·78]) after release from prison, 1-2 weeks after discharge from hospital (1·35 [1·11-1·63]), when being dispensed opioids for pain (after ≥4 weeks) or benzodiazepines (entire use period), and from 3 weeks after discontinuing antipsychotics. The incidence of non-fatal overdose was reduced during use of MOUD (aIRRs ranging from 0·33 [0·26-0·42] to 0·41 [0·25-0·67]) and when in prison (0·12 [0·08-0·19]).

INTERPRETATION

Expanding access to and increasing support for stable and long-term medication for the management of opioid use disorder, improving continuity of care when transitioning between service systems, and ensuring safe prescribing and medication monitoring processes for medications that reduce respiratory function (eg, benzodiazepines) could decrease the incidence of non-fatal overdose.

FUNDING

Murdoch Children's Research Institute and National Health and Medical Research Council.

A Critical Review of the Social and Behavioral Contributions to the Overdose Epidemic

More than 750,000 people in the United States died from an overdose between 1999 and 2018; two-thirds of those deaths involved an opioid. In this review, we present trends in opioid overdose rates during this period and discuss how the proliferation of opioid prescribing to treat chronic pain, changes in the heroin and illegally manufactured opioid synthetics markets, and social factors, including deindustrialization and concentrated poverty, contributed to the rise of the overdose epidemic. We also examine how current policies implemented to address the overdose epidemic may have contributed to reducing prescription opioid overdoses but increased overdoses involving illegal opioids. Finally, we identify new directions for research to understand the causes and solutions to this critical public health problem, including research on heterogeneous policy effects across social groups, effective approaches to reduce overdoses of illegal opioids, and the role of social contexts in shaping policy implementation and impact.

Modelling the intervention effect of opioid agonist treatment on multiple mortality outcomes in people who inject drugs: a three-setting analysis

BACKGROUND

Opioid agonist treatment (OAT) reduces many of the harms associated with opioid dependence. We use mathematical modelling to comprehensively evaluate the overall health benefits of OAT in people who inject drugs in Perry County (KY, USA), Kyiv (Ukraine), and Tehran (Iran).

METHODS

We developed a dynamic model of HIV and hepatitis C virus (HCV) transmission, incarceration, and mortality through overdose, injury, suicide, disease-related and other causes. The model was calibrated to site-specific data using Bayesian methods. We evaluated preventable drug-related deaths (deaths due to HIV, HCV, overdose, suicide, or injury) averted over 2020-40 for four scenarios, added incrementally, compared with a scenario without OAT: existing OAT coverage (setting-dependent; community 4-11%; prison 0-40%); scaling up community OAT to 40% coverage; increasing average OAT duration from 4-14 months to 2 years; and scaling up prison-based OAT.

OUTCOMES

Drug-related harms contributed differentially to mortality across settings: overdose contributed 27-47% (range of median projections) of preventable drug-related deaths over 2020-40, suicide 6-17%, injury 3-17%, HIV 0-59%, and HCV 2-18%. Existing OAT coverage in Tehran (31%) could have a substantial effect, averting 13% of preventable drug-related deaths, but will have negligible effect (averting <2% of preventable drug-related deaths) in Kyiv and Perry County due to low OAT coverage (<4%). Scaling up community OAT to 40% could avert 12-24% of preventable drug-related deaths, including 13-22% of overdose deaths, with greater effect in settings with significant HIV mortality (Tehran and Kyiv). Improving OAT retention and providing prison-based OAT would have a significant additional effect, averting 27-51% of preventable drug-related deaths.

INTERPRETATION

OAT can substantially reduce drug-related harms, particularly in settings with HIV epidemics in people who inject drugs. Maximising these effects requires research and investment into achieving higher coverage and provision and longer retention of OAT in prisons and the community.

FUNDING

UK National Institute for Health Research, US National Institute on Drug Abuse.

Opioid Use and Chronic Infections: The Value of Addressing the Syndemic in Correctional Settings Via Telemedicine Guidance and Broader Use of Long-Acting Medications

In the United States, we are experiencing linked epidemics (a syndemic) of substance use disorders (SUDs) and infections associated with drug use, including unsafe injecting and unsafe sex in exchange for drugs or money. Current drug laws, together with risk-taking behavior among persons with SUDs, contribute to disproportionately high prevalences of these conditions in correctional settings. Detection and treatment of diseases with a high impact on public health are best addressed in the settings where such conditions are most prevalent (ie, jails and prisons for SUDs and chronic infections). The effectiveness, safety, cost of care. and public health impact of these conditions can be improved by means of broader screening and expanded access to specialty consultations through telemedicine/telehealth, along with broader use of long-acting medications for the treatment of human immunodeficiency virus and SUDs. Expanding telemedicine/telehealth, first for specialties which do not require advanced technology (eg, infectious diseases, addictions), can eventually lead to further advancements in correctional healthcare.

"My first 48 hours out": drug users' perspectives on challenges and strategies upon release from prison

BACKGROUND

Prisoners report much higher prevalence rates of drug use and more harmful consumption patterns than the general population. People who use drugs have above-average experiences with the criminal justice system in general, and the prison system and subsequent release situations in particular. Release from prison is associated with increased mortality rates among drug users due to the risk of overdose. The EU-funded project 'My first 48 hours out' aimed to address the gaps in continuity of care for long-term drug users in prison and upon release, with a special focus on drug user's perspectives on needs and challenges upon release.

METHODS

A multi-country (Belgium, France, Germany and Portugal) qualitative study was set up to explore drug users' perceptions of drug use and risk behaviour upon prison release, experiences of incarceration and release, and strategies to avoid risks when being released. In total, 104 prisoners and recently released persons with a history of drug use participated in semi-structured interviews and focus groups discussions on these topics.

RESULTS

Respondents pointed out that there are numerous challenges for people who use drugs when released from prison. Lack of stable housing and employment support were frequently mentioned, as well as complex administrative procedures regarding access to services, health insurance and welfare benefits. Besides structural challenges, individual issues may challenge social reintegration like 'old habits', mental health problems and disrupted social networks. As a result, (ex-)prisoners adopt individual strategies to cope with the risks and challenges at release.

CONCLUSION

Measures to prepare prisoners for release often do not focus on the individual and specific challenges of persons who use drugs. Psychosocial and medical support need to be improved and adjusted to drug users' needs inside and outside prison. To improve the quality and continuity of care around release, the perspectives and coping strategies of people who use drugs should be used to better address their needs and barriers to treatment.

Use of non-prescribed buprenorphine in the criminal justice system: Perspectives of individuals recently released from incarceration

Buprenorphine, an effective treatment for opioid use disorder (OUD), remains underutilized in many U.S. jails and prisons. However, use of non-prescribed (i.e., diverted) buprenorphine has been reported in these settings. The current study examined non-prescribed buprenorphine use experiences in correctional and community contexts. The study conducted face-to-face interviews with 300 adults with OUD/opioid misuse and recent incarceration, recruited in Baltimore, MD, and New York, NY (n = 150 each). Illicit/non-prescribed opioid use during incarceration was reported by 63% of participants; 39% reported non-prescribed buprenorphine. Non-prescribed buprenorphine was considered the most widely available opioid in jails/prisons in both states (81% reported "very" or "somewhat" easy to get). The average price of non-prescribed buprenorphine in jail/prison was ~10× higher than in the community (p < 0.001). Participants were more likely to endorse getting high/mood alteration as reasons for using non-prescribed buprenorphine during incarceration, but tended to ascribe therapeutic motives to use in the community (e.g., self-treatment; p < 0.001). Multivariable logistic regression analyses showed that different individual-level characteristics were associated with history of non-prescribed buprenorphine use during incarceration and in the community. Use of non-prescribed buprenorphine during incarceration was associated with younger age (p = 0.006) and longer incarceration history (p < 0.001), while use of non-prescribed buprenorphine in the community was associated with MD recruitment site (p = 0.001), not being married (p < 0.001), prior buprenorphine treatment experience (p < 0.001), and housing situation (p = 0.01). These findings suggest that different dynamics and demand characteristics underlie the use of non-prescribed buprenorphine in community and incarceration contexts, with implications for efforts to expand OUD treatment in correctional settings.

Deconstructing the 'cheque effect': short-term changes in injection drug use after receiving income assistance and associated factors

BACKGROUND AND AIMS

Disbursement of income assistance has been temporally associated with intensified drug use and related harms (coined the 'cheque effect'). However, relationships to injection drug use (IDU) remain understudied. We examined short-term 'cheque effects' and associated factors among people who inject drugs (PWID).

DESIGN

Cross-sectional analysis nested within a cohort study.

SETTING

Montreal, Quebec, Canada.

PARTICIPANTS

PWID receiving income assistance, with no employment income. A total of 613 PWID (median age 41, 83% male) contributed 3269 observations from 2011 to 2017.

MEASUREMENTS AND METHODS

At each cohort visit, an interviewer-administered questionnaire captured retrospective reports of injection-related behaviour during the 2-day periods (i) before and (ii) including/after receiving last month's income assistance payment (number of injections; drugs injected; any receptive syringe-sharing). The relative likelihood (odds) and magnitude (rate) of an increase in injection frequency ('cheque effect') were estimated in relation to social and behavioural factors using logistic and negative binomial regression in a covariate-adjusted two-part model.

FINDINGS

Prevalence of IDU and syringe-sharing were, respectively, 1.80 and 2.50 times higher in the days following versus preceding cheque receipt (P < 0.001). Among people with past-month IDU, most observations showed increased injection frequency (52%) or no change in injection frequency (44%). The likelihood of a 'cheque effect' was positively associated with cocaine injection [versus injection of other substances, odds ratio (OR) = 2.639, 95% confidence interval (CI) = 2.04-3.41], unstable housing (OR = 1.272, 95% CI = 1.03-1.57) and receiving opioid agonist therapy (OR =1.597, 95% CI = 1.27-2.00) during the same month. Magnitude of the 'cheque effect' was positively associated with cocaine injection [rate ratio (RR) = 1.795, 95% CI = 1.43-2.16], unstable housing (RR = 1.198, 95% CI = 1.02-1.38) and frequent injection (RR = 2.938, 95% CI = 2.43-3.44), but inversely associated with opioid agonist therapy (RR = 0.817, 95% CI = 0.68-0.95) and prescription opioid injection (RR = 0.794, 95% CI = 0.66-0.93).

CONCLUSION

Among people who inject drugs in Montreal, Canada, injection drug use and receptive syringe-sharing appear to be more prevalent in the 2 days after versus before receiving income assistance. The odds and rate of individual-level increases in injection frequency appear to be positively associated with cocaine injection (versus injection of other substances) and unstable housing.

Understanding overdose incidents in Canadian federal custody

BACKGROUND

While the community effects of the opioid-related drug crisis in Canada are well documented, limited detailed data is available on overdose trends among custodial populations. Given that this crisis has disproportionate impacts on justice involved persons, research is needed to understand the implications of this crisis within institutional settings.

METHODS

We examined all overdose incidents that occurred between the 2012/2013 and 2018/2019 fiscal years in a federal correctional institution in Canada. An incident report search was conducted to identify overdose related incidents during this period. Information about the incident and characteristics of the victim was collected from incident reports, investigations, and victim case files.

RESULTS

Over the period under examination, overdose incidents steadily increased (i.e., from 40 in 2012/2013, to 110 non-fatal incidents in 2018/2019), although there was considerable regional and institutional variation. The number of incidents involving opioids, particularly fentanyl, increased both in raw numbers and as a percentage of overall incidents (i.e., from 3% in 2012/2013 to 47% in 2017/2018, and 34% of non-fatal incidents in 2018/2019). Other substances continue to contribute to overdose incidents; in fact, non-opioid prescription medications (i.e., non-illicit medications such as anti-convulsant drugs and anti-depressants) remain the most common among intentional non-fatal incidents. Relative to the general in-custody population, victims of overdose incidents tended to be younger and were more likely to be serving a determinate sentence, be on a repeat federal sentence, and be serving time for robbery. Mental health conditions and histories of substance use were common.

CONCLUSION

The effects of the overdose crisis are pronounced within certain Canadian federal institutions, illustrated by a growing number of fentanyl-related incidents. Institutional variation and variation in incidents (e.g., substance and intentionality) highlight diversity in drug activities among this custodial population and the need for multi-faceted responses that are reflective of local situations.

Modeling the role of incarceration in HCV transmission and prevention amongst people who inject drugs in rural Kentucky

BACKGROUND

People who inject drugs (PWID) experience high incarceration rates, with current/recent incarceration being associated with increased hepatitis C virus (HCV) transmission. We assess the contribution of incarceration to HCV transmission amongst PWID in Perry County (PC), Kentucky, USA, and the impact of scaling-up community and in-prison opioid substitution therapy (OST), including the potential for reducing incarceration.

METHODS

A dynamic model of incarceration and HCV transmission amongst PWID was calibrated in a Bayesian framework to epidemiological and incarceration data from PC, incorporating an empirically estimated 2.8-fold (95%CI: 1.36-5.77) elevated HCV acquisition risk amongst currently incarcerated or recently released (<6 months) PWID compared to other PWID. We projected the percentage of new HCV infections that would be prevented among PWID over 2020-2030 if incarceration no longer elevated HCV transmission risk, if needle and syringe programmes (NSP) and OST are scaled-up, and/or if drug use was decriminalized (incarceration/reincarceration rates are halved) with 50% of PWID that would have been imprisoned being diverted onto OST. We assume OST reduces reincarceration by 10-42%.

RESULTS

Over 2020-2030, removing the effect of incarceration on HCV transmission could prevent 42.7% (95% credibility interval: 15.0-67.4%) of new HCV infections amongst PWID. Conversely, scaling-up community OST and NSP to 50% coverage could prevent 28.5% (20.0-37.4%) of new infections, with this increasing to 32.7% (24.5-41.2%) if PWID are retained on OST upon incarceration, 36.4% (27.7-44.9%) if PWID initiate OST in prison, and 45.3% (35.9-54.1%) if PWID are retained on OST upon release. decriminalization (with diversion to OST) could further increase this impact, preventing 56.8% (45.3-64.5%) of new infections. The impact of these OST interventions decreases by 2.1-28.6% if OST does not reduce incarceration.

CONCLUSION

Incarceration is likely to be an important contributor to HCV transmission amongst PWID in PC. Prison-based OST could be an important intervention for reducing this risk.

Violence-related deaths among people released from incarceration: protocol for a systematic review

INTRODUCTION

Young people and adults released from incarceration have a risk of dying from violence that far exceeds that in the general population. Despite this, evidence regarding the incidence, elevated risk and predictive factors for violence-related deaths after release have not yet been synthesised. This information is important to inform the development of evidence-based approaches to effectively prevent deaths from violence in this population. This systematic review will synthesise the literature examining the crude mortality rates (CMRs), standardised mortality ratios (SMRs) and predictive factors for violence-related deaths among people released from incarceration.

METHODS AND ANALYSIS

We searched key electronic health, social science and criminology databases (MEDLINE, PubMed, PsycINFO, Scopus, Web of Science, CINCH, Criminal Justice Abstracts) for peer-reviewed cohort studies published in English on 14^th September 2020. Our primary outcome of interest is violence-related deaths occurring in the community following release from incarceration. We will not restrict study eligibility by year of publication or age of participants. The Methodological Standard for Epidemiological Research (MASTER) scale will be used to assess the quality of included studies. If there are sufficient studies and homogeneity between studies, we will conduct meta-analyses to calculate pooled estimates of CMRs, SMRs or predictive factors for violence-related deaths. If there is a sufficient number of included studies, meta-regression will be conducted to examine the influence of subgroups and methodological factors on the CMRs, SMRs or predictive factors. If the studies do not report sufficient data, or if there is substantial heterogeneity, findings will be presented in a narrative form.

ETHICS AND DISSEMINATION

This review is exempt from ethics approval as it will synthesise findings from published studies that have already obtained ethics approval. Our findings will be disseminated through a peer-reviewed journal article, and national and international conference and seminar presentations.

TRIAL REGISTRATION DETAILS

This study is registered with PROSPERO (CRD42020209422).

Telemedicine increases access to buprenorphine initiation during the COVID-19 pandemic

Federal regulatory changes during the COVID-19 pandemic allow buprenorphine to be prescribed without an initial in-person evaluation. Prior to COVID-19, numerous barriers limited broad uptake of buprenorphine among people who use drugs at the system, provider, and patient levels, including lack of available DATA 2000 waivered clinicians to prescribe, stigma, and competing livelihood priorities. As two harm reduction primary care programs in New York State that care for people who use drugs and offer buprenorphine, one rural (Ithaca) and one urban (Manhattan), we have rapidly adopted telemedicine to initiate buprenorphine treatment. Our collective experience suggests that telemedicine for buprenorphine initiation is eliminating many traditional barriers to treatment, in particular for individuals leaving incarceration, and people who use drugs and access syringe service programs. Future models of buprenorphine treatment should incorporate telemedicine for buprenorphine initiation, which can be done in collaboration with community-based outreach and peer networks to engage people who use drugs. This regulatory change must be sustained beyond COVID-19, and is vital to increasing access to buprenorphine, closing the opioid use disorder treatment gap, and achieving greater health equity for people who use drugs.

The Justice System and Young Adults With Substance Use Disorders

Young adults' heightened vulnerability to substance use disorders (SUD) corresponds with their disproportionate representation in the criminal justice system. It is paramount that the justice system systemically recognize young adults as a group with distinct developmental needs and align reform efforts with advancements made in medical and public health fields to better address the needs of justice-involved young adults with SUD. This article warns against reliance on the justice system for engaging young adults with SUD in treatment and presents 4 principles that were developed by a workgroup participating in a longitudinal meeting of experts sponsored by Boston Medical Center's Grayken Center for Addiction. The goal of the principles is to support and guide policy and practice initiatives for developmentally appropriate justice responses to young adults with SUD. The article also reviews the evidence that underlies these principles and offers policy and practice considerations for their implementation.

The changing opioid crisis: development, challenges and opportunities

The current opioid epidemic is one of the most severe public health crisis in US history. Responding to it has been difficult due to its rapidly changing nature and the severity of its associated outcomes. This review examines the origin and evolution of the crisis, the pharmacological properties of opioids, the neurobiology of opioid use and opioid use disorder (OUD), medications for opioid use disorder (MOUD), and existing and promising approaches to prevention. The results of the review indicate that the opioid epidemic is a complex, evolving phenomenon that involves neurobiological vulnerabilities and social determinants of health. Successfully addressing the epidemic will require advances in basic science, development of more acceptable and effective treatments, and implementation of public health approaches, including prevention. The advances achieved in addressing the current crisis should also serve to advance the science and treatment of other substance use disorders.

Exploring Problematic Substance Use during Reentry from Prison to the Community: A Thematic Analysis

The reentry process from prison to the community is rife with obstacles. Substance use problems, in particular, can present significant barriers to successful reentry. However, little research has examined the various roles that substance use plays during reentry from the perspective of those reentering the community. The current study explores reentry experiences of people who have been recently released from prison with a specific focus on their experiences with substance use during the reentry process. Using thematic analysis, the present study explored substance use experiences from 26 semi-structured interviews. Seven main themes emerged: recovery and sobriety, substance use programs, relapse, substance use exposure, triggers and other challenges, impact of incarceration on substance use, and reflections about substance use. Within each of these broad themes, additional subthemes emerged. Findings suggest complex histories of substance use spanning ecological contexts, including family, neighborhood, and corrections facilities as well as provide support for the pervasive and persistent nature of substance use among previously incarcerated individuals. Implications for practice and policy are discussed as well as potential future directions for research.

Buprenorphine Treatment Intake and Critical Encounters following a Nonfatal Opioid Overdose

BACKGROUND

Individuals with prior opioid-related overdose events have an increased risk for opioid-related mortality. Buprenorphine is a partial agonist that has shown to be an effective medication for opioid use disorder (MOUD). Yet, few studies have investigated whether buprenorphine reduces the risk of opioid-related mortality following a nonfatal opioid-related overdose.

METHODS

A retrospective study was conducted on all overdose cases in Indiana between January 1, 2017 and December 31, 2017. Data were linked from multiple administrative sources. Cases were linked to vital records to assess mortality. Bivariate analyses were conducted to assess group differences between survivors and decedents. A series of multiple logistic regression models were used to determine main and interaction effects of opioid-related mortality.

RESULTS

Among the 10,195 nonfatal overdoses, 2.4% (247) resulted in a subsequent fatal overdose. Overdose decedents were on average 36.4 years-old, 66.8% male, 91.1% White, and 83.8% did not receive a buprenorphine dispensation. Incremental increases in the number of buprenorphine dispensations decreased the likelihood of fatal overdose by 94% (95% CI = 0.88-0.98, p = .001). Incremental increases in arrest encounters were found to significantly increase the likelihood of a fatal overdose (AOR = 2.16; 95% CI = 1.13-3.55). Arrest encounters were a significant moderator of the relationship between buprenorphine uptake effectiveness and drug-related mortality.

CONCLUSIONS

Analysis of linked data provided details of risk and protective factors of fatal overdose. Buprenorphine reduced the risk of death; however, criminal justice involvement remains an area of attention for diversion and overdose death prevention interventions.

Correlates of Non-fatal, Opioid Overdose among Women Who Use Opioids in Dar es Salaam, Tanzania

BACKGROUND

As opioid overdoses and deaths increase globally, little is known about these dimensions in Sub-Saharan Africa. In this paper, we explore factors associated with opioid overdose experiences among a sample of women who use opioids in Dar es Salaam, Tanzania.

METHODS

We conducted a cross-sectional survey with 200 women who use opioids in Dar es Salaam, Tanzania, recruited via respondent-driven sampling. We fitted unadjusted and adjusted log-binomial regression models with robust standard errors to examine associations between participant characteristics and reporting ever had an opioid overdose in terms of prevalence ratios.

RESULTS

Thirty-four percent (n = 68) of participants reported having ever had an opioid overdose. In the final adjusted model, having ever attempted to stop using heroin (adj. PR = 1.46, 95% CI: 1.01-2.12), sleeping outside in the past 6 months (adj. PR = 1.93, 95% CI: 1.29-2.91), injecting drugs (adj. PR = 1.78, 95% CI: 1.19-2.66), alcohol use (adj. PR = 1.56, 95% CI: 1.09-2.23), and having moderately severe to severe depression (adj. PR = 3.10, 95% CI: 1.07-8.97) were all found to be significantly associated with having ever had an opioid overdose.

CONCLUSIONS

We demonstrate factors associated with opioid overdose among women who use drugs in Tanzania that may not be addressed with injection-focused harm reduction efforts. Our findings suggest the need for overdose surveillance efforts and further work to characterize overdose risks in this context in order to design relevant, targeted interventions to prevent opioid overdose in sub-Saharan Africa.

Randomized trial of methadone treatment of arrestees: 24-month post-release outcomes

BACKGROUND

We report on the 24-month post-release outcomes of arrestees with opioid use disorder (OUD) enrolled in a randomized trial comparing three treatment approaches initiated in jail.

METHODS

Adults (N = 225) receiving medically supervised withdrawal from opioids in the Baltimore Detention Center within a few days of arrest were randomly assigned to: (1) interim methadone treatment plus patient navigation (IM + PN) started in the Detention Center; (2) IM; or (3) Enhanced Treatment-as-Usual (ETAU) consisting of detoxification with methadone and referral to treatment in the community. Participants in both methadone conditions could transfer to standard methadone treatment following release. Participants were interviewed at baseline, and 1, 3, 6, 12, and 24 months post-release. Urine was drug tested at follow-up and official arrest records were obtained.

RESULTS

On an intention-to-treat basis, there were no significant differences among the three conditions over the 24-month post-release period in terms of opioid- or cocaine-positive urine test results or self-reported opioid or cocaine use, meeting opioid or cocaine use disorder criteria, self-reported criminal behavior, or the number of official arrests. There were 9 fatal overdoses, none occurring during methadone treatment, and 109 hospitalizations unrelated to the study.

CONCLUSIONS

Given the high morbidity and mortality found in this population of arrestees and costs to society associated with their health care utilization and continued crime and arrests, research aimed at finding more effective interventions should be continued.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov: NCT02334215.

Buprenorphine Induction in a Rural Maryland Detention Center During COVID-19: Implementation and Preliminary Outcomes of a Novel Telemedicine Treatment Program for Incarcerated Individuals With Opioid Use Disorder

Over 10 million individuals pass through U.S. detention centers on an annual basis, with nearly two-thirds meeting criteria for drug dependence/abuse. Despite proven efficacy, treatment with medications for opioid use disorder (MOUD) is underutilized in jail settings-a gap that could be addressed using telemedicine. Here we describe a new program of telemedicine-based clinical provision of new/continuing buprenorphine treatment for individuals detained in a rural jail. Implementation objectives were completed between January and August 2020, and patient encounters were conducted between August 2020 and February 2021. We established (i) telemedicine hardware/software capability; (ii) a screening process; (iii) buprenorphine administration methods; (iv) necessary medical release procedures; (v) telemedicine encounter coordination and medication prescription procedures; and (vi) a research platform. Seven incarcerated patients have been treated, two of whom were referred from community treatment. Patients were mostly male (71%), non-Hispanic White (86%), and averaged 33 years old. All patients tested positive for an opioid upon intake and began/continued buprenorphine treatment in the jail. Average time to first MOUD appointment was 9 days and patients were maintained in treatment an average 21 days. Referrals for continuing community treatment were offered to all patients prior to discharge. We report successful implementation of telemedicine MOUD in a rural detention center, with treatment engagement and initiation occurring prior to the high-risk period of discharge. The fact that this program was launched during the height of the pandemic highlights the flexibility of telemedicine-based buprenorphine treatment. Challenges and obstacles to implementation of buprenorphine treatment in a correctional system are discussed.

Knowledge, attitudes, and acceptability of direct-acting antiviral hepatitis C treatment among people incarcerated in jail: A qualitative study

Introduction

While U.S. jails are critical sites for engagement in HCV care, short lengths-of-stay often do not permit treatment in jail. Therefore, linkage to HCV care after incarceration is crucial. However, little is known about HCV treatment acceptability among justice-involved individuals in U.S. jails. The goal of this study was to understand knowledge, attitudes, and acceptability of HCV treatment among people living with HCV in the New York City (NYC) jail system.

Methods

We recruited 36 HCV-antibody-positive individuals in the NYC jails using clinical data reports and performed semi-structured interviews to explore participants’ attitudes toward HCV treatment in jail and following return to the community. We continued interviews until reaching thematic saturation and analyzed interviews using an inductive, thematic approach.

Results

Participants were mostly male, Latina/o, with a mean age of 40 years. Nearly all were aware they were HCV antibody-positive. Two thirds of participants had some awareness of the availability of new HCV therapies. Key themes included: 1) variable knowledge of new HCV therapies affecting attitudes toward HCV treatment, 2) the importance of other incarcerated individuals in communicating HCV-related knowledge, 3) vulnerability during incarceration and fear of treatment interruption, 4) concern for relapse to active drug use and HCV reinfection, 5) competing priorities (such as other medical comorbidities, ongoing substance use, and housing), 6) social support and the importance of family.

Conclusions

Patient-centered approaches to increase treatment uptake in jail settings should focus on promoting HCV-related knowledge including leveraging peers for knowledge dissemination. In addition, transitional care programs should ensure people living with HCV in jail have tailored discharge plans focused on competing priorities such as housing instability, social support, and treatment of substance use disorders.

The association of criminal justice supervision setting with overdose mortality: a longitudinal cohort study

BACKGROUND AND AIMS

Despite the high prevalence of substance use among people in the US criminal justice system, little is known about the incidence of overdose mortality by use patterns, drug convictions and supervision setting. We examined the associations between these characteristics and overdose mortality.

DESIGN

Retrospective cohort study.

SETTING AND PARTICIPANTS

Individuals sentenced to prison, jail, probation or jail plus probation for a felony conviction in Michigan, USA from 2003 to 2006.

MEASUREMENTS

Using the National Death Index, we assessed overdose mortality to December 2012. We calculated overdose mortality rates by pre-sentence opioid use, drug convictions and supervision setting. Multivariable analyses were conducted using competing risks regression with time-varying covariates.

FINDINGS

Among 140 266 individuals followed over a mean of 7.84 years [standard deviation (SD) = 1.52], 14.9% of the 1131 deaths were due to overdose (102.8 per 100 000 person-years). Over the follow-up, more than half of overdose deaths occurred in the community (57.7%), nearly a third (28.8%) on probation and 12.8% on parole. The adjusted risk of overdose death was lower on probation [hazard ratio (HR) = 0.71, 95% confidence interval (CI) = 0.60, 0.85] than in the community without probation or parole (HR = 1.00) but not significantly different on parole (HR = 1.13, 95% CI = 0.87, 1.47). Pre-sentence daily opioid use (HR = 3.54, 95% CI = 3.24, 3.87) was associated with an increased risk. Drug possession (HR = 1.11, 95% CI = 0.93, 1.31) and delivery convictions (HR = 0.92, 95% CI = 0.77, 1.09) were not significantly associated with overdose mortality.

CONCLUSIONS

Based on the absolute or relative risk, parole, probation and community settings are appropriate settings for enhanced overdose prevention interventions. Ensuring that individuals with pre-sentence opioid use have access to harm reduction and drug treatment services may help to prevent overdose among people involved with the criminal justice system.

The Opioid-overdose Reduction Continuum of Care Approach (ORCCA): Evidence-based practices in the HEALing Communities Study

BACKGROUND

The number of opioid-involved overdose deaths in the United States remains a national crisis. The HEALing Communities Study (HCS) will test whether Communities That HEAL (CTH), a community-engaged intervention, can decrease opioid-involved deaths in intervention communities (n = 33), relative to wait-list communities (n = 34), from four states. The CTH intervention seeks to facilitate widespread implementation of three evidence-based practices (EBPs) with the potential to reduce opioid-involved overdose fatalities: overdose education and naloxone distribution (OEND), effective delivery of medication for opioid use disorder (MOUD), and safer opioid analgesic prescribing. A key challenge was delineating an EBP implementation approach useful for all HCS communities.

METHODS

A workgroup composed of EBP experts from HCS research sites used literature reviews and expert consensus to: 1) compile strategies and associated resources for implementing EBPs primarily targeting individuals 18 and older; and 2) determine allowable community flexibility in EBP implementation. The workgroup developed the Opioid-overdose Reduction Continuum of Care Approach (ORCCA) to organize EBP strategies and resources to facilitate EBP implementation.

CONCLUSIONS

The ORCCA includes required and recommended EBP strategies, priority populations, and community settings. Each EBP has a "menu" of strategies from which communities can select and implement with a minimum of five strategies required: one for OEND, three for MOUD, and one for prescription opioid safety. Identification and engagement of high-risk populations in OEND and MOUD is an ORCCArequirement. To ensure CTH has community-wide impact, implementation of at least one EBP strategy is required in healthcare, behavioral health, and criminal justice settings, with communities identifying particular organizations to engage in HCS-facilitated EBP implementation.

COVID-19 and the health of people who use drugs: What is and what could be?

SARS-CoV-2, the virus that causes COVID-19, has changed the world as we know it, and continues to do so. How COVID-19 affects people who use drugs, the environments in which they live, and capacities of response, warrants immediate attention. This special issue begins to map how COVID-19 is altering the health of people who use drugs, including in relation to patterns of drug use, service responses, harms that may relate to drug use, interventions to reduce risk of harms, COVID-19 health, and drug policies. We emphasise the need to envisage COVID-19 and its effects as a matter of intersecting ‘complex adaptive systems’: that is, the impacts of COVID-19 extend beyond the virus and related illness conditions to encompass multiple social, cultural, economic, policy and political effects; and these affect the health of people who use drugs directly as well as indirectly by altering the risk and enabling environments in which they live. We synthesize emergent evidence on the impact of COVID-19 on the health of people who use drugs. A key concern we identify is how to sustain policy and service delivery improvements prompted by COVID-19. We need to maintain an ethos of emergent adaptation and experimentation towards the creation of safer environments in relation to the health of people who use drugs.

Suicide and Probation: a systematic review of the literature

A narrative systematic review was undertaken of the literature concerning the health of people on probation. In this paper, we provide an up-to-date summary of what is known about suicide and suicidal ideation and probation. This includes estimates of prevalence and possible predictors of suicide and suicidal ideation. Searches were conducted on nine databases from January 2000 to May 2017, key journals from 2000 to September 2017, and the grey literature. A total of 5125 papers were identified in the initial electronic searches but after careful double-blind review only one research paper related to this topic met our criteria, although a further 12 background papers were identified which are reported. We conclude that people on probation are a very high risk group for completed suicide, and factors associated with this include drug overdose, mental health problems, and poor physical health. There is a clear need for high quality partnership working between probation and mental health services, and investment in services, to support appropriate responses to suicide risk.

Fifteen years of heroin-assisted treatment in a Swiss prison-a retrospective cohort study

Background

In the context of the current US opioid crisis and the compelling fact that a quarter to a third of all those addicted to heroin pass through its prisons and jails each year, the care of incarcerated opioid-using individuals (OUI) needs to be improved.

Aims

Little has been published on the effectiveness or outcomes of heroin-assisted treatment (HAT), a treatment option for severely dependent OUI delivered in a prison setting. The aim of this study was therefore to evaluate such treatment since its implementation. The primary objective was to investigate whether heroin-assisted treatment was associated with severe detrimental health outcomes. The secondary objective was to compare the heroin-assisted treatment group with the general prison population in terms of occupational functioning.

Design

Retrospective cohort study

Setting

An open prison with 120 places

Subjects

Data on 1885 male prisoners with a total of 2239 imprisonment periods between 2000 and 2015 was available. Ninety-seven inmates in heroin-assisted treatment were compared with 1788 inmates from the general prison population (reference group).

Measurements

Mortality, medical complications (including overdoses), and work performance (days worked, sick days, and monthly wages earned).

Findings

Inmates receiving HAT were on average 1 year younger (33.8 vs. 34.9 years), had longer prison stays (7.3 vs. 3.0 months), were more often of Swiss nationality (68.0% vs. 28.9%), and had committed more drug- and property-related offenses (49.5% vs. 23.2% and 63.9% vs. 38.3%, respectively) compared to the reference group. No serious heroin-related medical complication occurred during the 15-year window of observation among inmates with heroin-assisted treatment. Their work performance was comparable to that of the reference group.

Conclusions

This study shows that heroin-assisted treatment can be a valuable treatment option for severely dependent OUI during imprisonment, can be delivered safely by prison health staff over extended periods of time, and allows OUI in treatment to achieve work performance rates comparable to that of the general prison population.

Do interruptions to the continuity of methadone maintenance treatment in specialist addiction settings increase the risk of drug-related poisoning deaths? A retrospective cohort study

AIMS

To examine the risk of mortality associated with interruptions to the continuity of methadone maintenance treatment (MMT), including transfers between services, in opioid-dependent individuals attending specialist addiction services.

DESIGN

Retrospective cohort study using addiction services and primary care dispensing records, the National Methadone Register and National Drug-Related Death Index (NDRDI).

SETTING

Geographically defined population in Dublin, Ireland.

PARTICIPANTS

A total of 2899 people prescribed and dispensed methadone in specialist addiction services between January 2010 and December 2015. There were five exposure groups: weeks 1-4 following transfer between treatment providers; weeks 1-4 out of treatment; weeks 5-52 out of treatment; weeks 1-4 of treatment initiation; and weeks 5+ of continuous treatment (reference category).

MEASUREMENTS

Primary outcome: drug-related poisoning (DRP) deaths. Secondary outcome: all-cause mortality (ACM). Mortality rates calculated by dividing number of deaths (DRP; ACM) in exposure groups by person-years exposure. Unadjusted and adjusted Poisson regression (covariates age, sex, incarceration, methadone dose and comorbidities) estimated differences in mortality rates.

FINDINGS

There were 154 ACM deaths, 55 (35.7%) identified as DRP deaths. No deaths were observed in the first month following transfer between treatment providers. The risk of DRP mortality was highest in weeks 1-4 out of treatment [adjusted relative risk (aRR = 4.04, 95% confidence interval (CI) = 1.43-11.43, P = 0.009] and weeks 1-4 of treatment initiation (ARR = 3.4, 95% CI = 1.2-9.64, P = 0.02). Similarly, risk of ACM was highest in weeks 1-4 out of treatment (ARR = 11.78, 95% CI = 7.73-17.94, P < 0.001), weeks 1-4 of treatment initiation (aRR = 5.11, 95% CI = 2.95-8.83, P < 0.001) and weeks 5-52 off treatment (aRR = 2.04, 95% CI = 1.2-3.47, P = 0.009).

CONCLUSIONS

Interruptions to the continuity of methadone maintenance treatment by treatment provider do not appear to be periods of risk for drug-related poisoning or all-cause mortality deaths. Risk of drug related poisoning and all-cause mortality deaths appears to be greatest during the first 4 weeks of treatment initiation/re-initiation and after treatment cessation.

Signal of increased opioid overdose during COVID-19 from emergency medical services data

BACKGROUND

Individuals with opioid use disorder may be at heightened risk of opioid overdose during the COVID-19 period of social isolation, economic distress, and disrupted treatment services delivery. This study evaluated changes in daily number of Kentucky emergency medical services (EMS) runs for opioid overdose between January 14, 2020 and April 26, 2020.

METHODS

We evaluated the statistical significance of the changes in the average daily EMS opioid overdose runs in the 52 days before and after the COVID-19 state of emergency declaration, March 6, 2020.

RESULTS

Kentucky EMS opioid overdose daily runs increased after the COVID-19 state emergency declaration. In contrast, EMS daily runs for other conditions leveled or declined. There was a 17% increase in the number of EMS opioid overdose runs with transportation to an emergency department (ED), a 71% increase in runs with refused transportation, and a 50% increase in runs for suspected opioid overdoses with deaths at the scene. The average daily EMS opioid overdose runs with refused transportation increased significantly, doubled to an average of 8 opioid overdose patients refusing transportation every day during the COVID-19-related study period.

CONCLUSIONS

This Kentucky-specific study provides empirical evidence for concerns that opioid overdoses are rising during the COVID-19 pandemic and calls for sharing of observations and analyses from different regions and surveillance systems with timely data collection (e.g., EMS data, syndromic surveillance data for ED visits) to improve our understanding of the situation, inform proactive response, and prevent another big wave of opioid overdoses in our communities.

Feasibility and acceptability of take-home naloxone for people released from prison in New South Wales, Australia

INTRODUCTION AND AIMS

To assess the feasibility and acceptability of a take-home naloxone program for people with a history of opioid use released from prison in New South Wales, Australia.

DESIGN AND METHODS

Cross-sectional interviews with people with a history of opioid use who were recently released from prison (n = 105), and semi-structured interviews with key clinical and operational staff of Justice Health and Forensic Mental Health Network and Corrective Services NSW (n = 9).

RESULTS

Among people with a history of opioid use who had recently left prison, there was very high awareness of the elevated risk of overdose following release from prison (95%) and the potential for naloxone to reverse an opioid overdose (97%). Participants considered that their personal risk of overdose was low, despite ongoing opioid use being common. Participants were largely supportive of take-home naloxone, but the majority (83%) stated that proactively obtaining naloxone would be a low priority for them following release. Key informants were supportive of introducing naloxone training and supply and identified barriers to implementation, including adequate resourcing, identifying the population for training, and developing an appropriate model of training and implementation.

DISCUSSION AND CONCLUSION

There was widespread support for naloxone training in custody and distribution at release among people recently released from prison and key stakeholders in health-care provision and prisons administration. As proactively accessing naloxone is a low priority for patients, naloxone supply at release may be more effective than programs that refer releasees to local pharmacies, but developing a sustainable supply model requires consideration of several barriers.

The relationship between incarceration history and overdose in North America: A scoping review of the evidence

INTRODUCTION

Rates of opioid overdose (OD) have risen to unprecedented numbers and more than half of incarcerated individuals meet the criteria for substance use disorder, placing them at high risk. This review describes the relationship between incarceration history and OD.

METHODS

A scoping review was conducted and criteria for inclusion were: set in North America, published in English, and non-experimental study of formerly incarcerated individuals. Due to inconsistent definitions of opioid OD, we included all studies examining OD where opioids were mentioned.

RESULTS

The 18 included studies were all published in 2001 or later. Four associations between incarceration history and OD were identified: (1) six studies assessed incarceration history as a risk factor for OD and four found a significantly higher risk of OD among individuals with a history of incarceration compared to those without; (2) nine studies examined the rate of OD compared to the general population: eight found a significantly higher risk of fatal OD among those with a history of incarceration and three documented the highest risk of death immediately following release; (3) six studies found demographic, substance use and mental health, and incarceration-related risk factors for OD among formerly incarcerated individuals; and (4) four studies assessed the proportion of deaths due to OD and found a range from 5 % to 57 % among formerly incarcerated individuals.

DISCUSSION

Findings support the growing call for large-scale implementation of evidence-based OD prevention interventions in correctional settings and among justice-involved populations to reduce OD burden in this high-risk population.

Understanding the client characteristics of Aboriginal residential alcohol and other drug rehabilitation services in New South Wales, Australia

BACKGROUND

Aboriginal alcohol and other drug residential rehabilitation (residential rehabilitation) services have been providing treatment in Australia of over 50 years. However, there are no studies in Australia or internationally that document characteristics of clients attending Indigenous residential rehabilitation services worldwide. This is the first multi-site paper to describe key client characteristics of six Indigenous (hereafter Aboriginal Australians as the term recommended by the Aboriginal Health and Medical Research Council of New South Wales) residential rehabilitation services in Australia.

METHODS

All recorded client admissions between 1 January 2011 to 31 December 2016 were considered from six operating services in the Australian state of New South Wales. Data collected were classified into categories based on demographics, treatment utilisation, substance use, mental health and quality of life characteristics. Means, median and percentages were calculated (where appropriate).

RESULTS

There were 2645 admissions across the six services in the study period, with an average of 440 admissions per year across all services. Participants were aged between 26 to 35 years, with fewest participants aged 46 +. Program length ranged from 12 to 52 weeks (mean of 12 weeks). The completion rates and length of stay for each service ranged from less than two to more than 12 weeks. The principal drug of choice was alcohol and amphetamines in half of the services. Not all services used them, but a range of tools were used to measure treatment, substance use and mental health or quality of life outcomes.

CONCLUSION

This study is the first internationally to describe the key features of multiple Aboriginal residential rehabilitation services. The variation in tools used to collect client data made it difficult to compare client characteristics across services. Future research could explore predictors of treatment completion, identify opportunities for standardisation in client assessments and validate cultural approaches of care. These efforts would need to be guided by Aboriginal leadership in each service.

Cost-effectiveness analysis of chronic hepatitis C treatment in the prison population in Spain

Objectives

To evaluate the cost-effectiveness of direct-acting antiviral (DAAs) treatment versus non-treatment in prisoners awaiting treatment for chronic hepatitis C (CHC) and to analyse the clinical and economic impact of the treatment on liver complications and mortality.

Material and method

A lifetime Markov model was developed to simulate treatment and disease progression from an estimated cohort of 4,408 CHC prisoners treated with DAAs over 2 years (50% of patient each year) versus no treatment. In the treated cohort, a sustained viral response of 95% was associated. Patient characteristics, transition probabilities, utilities and costs (pharmacological and healthcare states) were obtained from published literature. The model estimated healthcare costs and benefits, incremental cost-utility ratio (ICUR) based on total costs and the quality-adjusted life year (QALY) and avoided clinical events. A National Healthcare System perspective was adopted with a 3% annual discount rate for both costs and health outcomes. Sensitivity analyses were performed to assess uncertainty.

Results

In the DDA treated cohort, the model estimated a decrease of 92% of decompensated cirrhosis and 83% of hepatocellular carcinoma, 88% liver-related mortality cases were reduced, 132 liver transplants were avoided. The treatment achieved an additional 5.0/QALYs (21.2 vs. 16.2) with an incremental cost of €3,473 (€24,088 vs. €20,615) per patient with an ICUR of €690 per QALY gained.

Discussion

Considering the willingness-to-pay threshold used in Spain (€22,000-30,000/QALY), DAAs treatment for prisoners with CHC is a highly cost-effective strategy, reduces infection transmission, increases survival and reduces complications due to liver disease, as well as the cost associated with its management.

Optimizing the impact of medications for opioid use disorder at release from prison and jail settings: A microsimulation modeling study

BACKGROUND

We examined the impact of expanded access to medications for opioid use disorder (MOUD) in a unified prison and jail system on post-release, opioid-related overdose mortality.

METHODS

We developed a microsimulation model to simulate a population of 55,000 persons at risk of opioid-related overdose mortality in Rhode Island. The effect of an extended-release (XR) naltrexone only intervention and the effect of providing access to all three MOUD (i.e., methadone, buprenorphine, and XR-naltrexone) at release from incarceration on cumulative overdose death over eight years (2017-2024) were compared to the standard of care (i.e., limited access to MOUD).

RESULTS

In the standard of care scenario, the model predicted 2385 opioid-related overdose deaths between 2017 and 2024. An XR-naltrexone intervention averted 103 deaths (4.3% reduction), and access to all three MOUD averted 139 deaths (5.8% reduction). Among those with prior year incarceration, an XR-naltrexone only intervention and access to all three MOUD reduced overdose deaths by 22.8% and 31.6%, respectively.

CONCLUSIONS

Expanded access to MOUD in prison and jail settings can reduce overdose mortality in a general, at-risk population. However, the real-world impact of this approach will vary by levels of incarceration, treatment enrollment, and post-release retention.

Does criminal justice stigma affect health and health care utilization? A systematic review of public health and medical literature

PURPOSE

This paper aims to determine whether criminal justice (CJ) stigma affects health outcomes and health care utilization.

DESIGN/METHODOLOGY/APPROACH

The authors reviewed medical and public health literature through May 2020. Structured terms were used to search four databases identifying articles that related to CJ stigma. Included articles were in English, examined CJ stigma and had people with CJ involvement as subjects. The studies without health outcomes were excluded. Quantitative and qualitative studies were reviewed and assessed for bias. Results were synthesized into a systematic review.

FINDINGS

The search yielded 25 studies relating to CJ stigma and health. Three stigma domains were described in the literature: perceived or enacted, internalized and anticipated stigma. Tenuous evidence linked CJ stigma to health directly (psychological symptoms) and indirectly (social isolation, health care utilization, high-risk behaviors and housing or employment). Multiple stigmatized identities may interact to affect health and health care utilization.

RESEARCH LIMITATIONS/IMPLICATIONS

Few studies examined CJ stigma and health. Articles used various measures of CJ stigma, but psychometric properties for instruments were not presented. Prospective studies with standard validated measures are needed.

PRACTICAL IMPLICATIONS

Understanding whether and how CJ stigma affects health and health care utilization will be critical for developing health-promoting interventions for people with CJ involvement. Practical interventions could target stigma-related psychological distress or reduce health care providers' stigmatizing behaviors.

ORIGINALITY/VALUE

This was the first systematic review of CJ stigma and health. By providing a summary of the current evidence and identifying consistent findings and gaps in the literature, this review provides direction for future research and highlights implications for policy and practice.

Reducing overdose after release from incarceration (ROAR): study protocol for an intervention to reduce risk of fatal and non-fatal opioid overdose among women after release from prison

BACKGROUND

Drug overdose is the leading cause of death after release from prison, and this risk is significantly higher among women compared to men. Within the first 2 weeks after release, the risk of death from drug overdose is 12.7 times higher than the general population, with risk of death further elevated among females. Although female inmates have higher rates of opioid use disorder and post-release overdose fatality, justice-involved women are under-represented in studies of medications for opioid use disorder. The Reducing Overdose After Release from Incarceration (ROAR) pilot intervention and evaluation (recruitment June 2019 through December 2020) aims to reduce opioid overdose among women released to the community following incarceration in state prison. The evaluation further assesses induction, acceptance and effectiveness of extended release naltrexone in a female post-prison population.

METHODS/DESIGN

In the week prior to their release, female adults in custody with moderate to severe opioid use disorder start treatment with extended release naltrexone, an injectable opioid antagonist that blocks the effects of opioids for up to 1 month. All ROAR participants receive training to use naloxone rescue kits and are provided nasal naloxone at release. Ongoing support from a certified recovery mentor to facilitate sustained engagement with treatment for substance use disorders begins in the month prior to release from prison and continues for 6 months in community. We evaluate the association between ROAR participation and the primary outcome of opioid overdose. Using administrative data provided by the Oregon Department of Corrections and the Oregon Health Authority, we compare the odds of overdose among ROAR participants versus a comparison group of females released from prison during the study period. Evaluation activities in community includes survey and qualitative interviews for 6 months post release, as well as a review of clinic records to assess retention on medication among the pilot cohort (N = 100).

DISCUSSION

ROAR is a collaboration between Oregon's public health, criminal justice, and medical communities. The ROAR intervention and evaluation provide critical information on improving interventions to prevent opioid overdose and improve retention on treatment in community in an overlooked, high-risk population: incarcerated women re-entering the community.

TRIAL REGISTRATION

Clinical Trials.gov TRN: NCT03902821 .

Methamphetamine use, health and criminal justice system outcomes: A systematic review

ISSUES

Methamphetamine use is a problem for health and criminal justice systems (CJS) worldwide. Methamphetamine is used at higher rates in CJS-involved populations than the general community. This systematic review synthesises the evidence for health and CJS outcomes post-CJS contact for people reporting pre-CJS methamphetamine use.

APPROACH

Academic databases were searched to identify peer-reviewed original studies using a longitudinal design that investigated associations between pre-CJS methamphetamine use and health and criminal justice outcomes after CJS contact. Identified studies were screened in two stages: title and abstract, then full-text. Data from the included studies were extracted and analysed. Results are reported in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement.

KEY FINDINGS

Nine studies met the inclusion criteria: five investigated health and four investigated CJS outcomes. Pre-CJS methamphetamine use was associated with subsequent hospitalisation for drug-induced psychosis, increased risk of recidivism and higher crime costs after CJS contact. Pre-CJS methamphetamine use was not associated with subsequent hospitalisation for non-drug induced psychosis or post-release mortality.

IMPLICATIONS

Current evidence suggests that pre-CJS contact methamphetamine use increases the risk of subsequent drug-induced psychosis and recidivism. There is a need for more longitudinal research that measures mediators and moderators of health and criminal justice outcomes after CJS contact, to inform targeted prevention.

CONCLUSION

Methamphetamine use is a major problem that is contributing to serious mental illness and recidivism among CJS-involved populations. Prioritising treatment during CJS contact is recommended. Further research to identify key opportunities during health service and CJS contact for intervention is needed.

Recent incarceration and risk of first-time injection initiation assistance: A prospective cohort study of persons who inject drugs

BACKGROUND

Given the prevalence and harms of incarceration among persons who inject drugs (PWID) and their role in injection drug use initiation, we aimed to investigate whether recent incarceration influences the likelihood PWID assist others in their first-ever injection.

METHODS

Prospective cohort study of PWID in Vancouver, Canada who had their PReventing Injecting by Modifying Existing Responses (PRIMER) baseline visit between December 2014 and May 2017, reported never providing injection initiation assistance previously, and had ≥1 follow-up visit. The primary outcome, provision of injection initiation assistance, was defined via self-report as helping anybody inject for the first time in the past six months. The primary exposure was recent incarceration, i.e., self-report of being jailed, imprisoned or detained in the past six months. Participants were assessed biannually until November 2017, drop-out, or their first report of the primary outcome.

RESULTS

1,199 PWID (62.1% male; mean (SD) age, 44.4 (12.3) years) were included in our study. Across 4,171 follow-up visits, 67 participants (5.6%) reported providing injection initiation assistance. The proportion of participants reporting recent incarceration varied between 2.4% to 5.1% per follow-up visit. Based on a multivariable discrete-time proportional hazards regression analysis, recent incarceration was associated with an increased risk of providing injection initiation assistance during the same six-month period (adjusted hazard ratio, 2.64; 95% CI, 1.19 to 5.86).

CONCLUSIONS

The observed association between recent incarceration and risk of providing injection initiation assistance suggests that incarceration could be contributing to the expansion of injection drug use practices within vulnerable populations over time.

Modelling integrated antiretroviral treatment and harm reduction services on HIV and overdose among people who inject drugs in Tijuana, Mexico

INTRODUCTION

The HIV epidemic in Tijuana, Mexico is concentrated in key populations, including people who inject drugs (PWID). However, HIV interventions among PWID are minimal, and federal funding was provided for compulsory abstinence programmes associated with HIV and overdose. Alternatively, opioid agonist therapy reduces overdose, reincarceration, HIV, while improving antiretroviral therapy (ART) outcomes. We assessed potential impact and synergies of scaled-up integrated ART and opioid agonist therapy, compared to scale-up of each separately, and potential harms of compulsory abstinence programmes on HIV and fatal overdose among PWID in Tijuana.

METHODS

We developed a dynamic model of HIV transmission and overdose among PWID in Tijuana. We simulated scale-up of opioid agonist therapy from zero to 40% coverage among PWID. We evaluated synergistic benefits of an integrated harm reduction and ART scale-up strategy (40% opioid agonist therapy coverage and 10-fold ART recruitment), compared to scale-up of each intervention alone or no scale-up of low coverage ART and no harm reduction). We additionally simulated compulsory abstinence programmes (associated with 14% higher risk of receptive syringe sharing and 76% higher odds of overdose) among PWID.

RESULTS

Without intervention, HIV incidence among PWID could increase from 0.72 per 100 person-years (PY) in 2020 to 0.92 per 100 PY in 2030. Over ten years, opioid agonist therapy scale-up could avert 31% (95% uncertainty interval (UI): 18%, 46%) and 22% (95% UI: 10%, 28%) new HIV infections and fatal overdoses, respectively, with the majority of HIV impact from the direct effect on HIV transmission due to low ART coverage. Integrating opioid agonist therapy and ART scale-up provided synergistic benefits, with opioid agonist therapy effects on ART recruitment/retention averting 9% more new infections compared to ART scale-up alone. The intervention strategy could avert 48% (95% UI: 26%, 68%) of new HIV infections and one-fifth of fatal overdoses over ten years. Conversely, compulsory abstinence programmes could increase HIV and overdoses.

CONCLUSIONS

Integrating ART with opioid agonist therapy could provide synergistic benefits and prevent HIV and overdoses among PWID in Tijuana, whereas compulsory abstinence programmes could cause harm. Policymakers should consider the benefits of integrating harm reduction and HIV services for PWID.