The association of prison security level with mortality after release from prison: a retrospective national cohort study (2000–16)

Estimated effects of opioid agonist treatment in prison on all-cause mortality and overdose mortality in people released from prison in Norway: a prospective analysis of data from the Norwegian Prison Release Study (nPRIS)

BACKGROUND

Overdose is the leading cause of death for people released from prison, and opioid agonist treatment is associated with reductions in mortality after imprisonment. However, few studies have explored the interplay of the potential modifiable risk factors and protective factors for mortality after release from prison. We aimed to describe all-cause mortality and overdose mortality among individuals released from Norwegian prisons during 2000-22 and to identify pre-existing risk factors associated with both types of mortality among these individuals for 6 months.

METHODS

For this prospective analysis, we used data from the Norwegian Prison Release Study (nPRIS), which includes all people in prison in Norway between Jan 1, 2000, and Dec 31, 2022; the Norwegian Cause of Death Registry; the Norwegian Prison Registry; the Norwegian Patient Registry; and Statistics Norway. All prisons in Norway that were open during this period were included. People who did not have a Norwegian personal identification number or were serving their sentence outside of prison units were excluded from this analysis. To identify pre-existing risk factors associated with all-cause and overdose mortality among people released from prison, we left-censored the observation period on Jan 1, 2010, creating a subsample of individuals. We calculated crude mortality rates (CMRs) and corresponding 95% CIs as the number of deaths per 100 000 person-years for several time periods after release. The primary outcomes were all-cause mortality and overdose mortality according to the ICD-10, assessed in all participants and analysed via two separate Cox proportional-hazards models.

FINDINGS

The total nPRIS cohort included 112 877 individuals released from prison in Norway between 2000 and 2022, 11 995 (10·6%) of whom were female and 100 865 (89·4%) of whom were male. We identified 13 004 instances of all-cause mortality and 3085 instances of overdose mortality during the 1 463 035 person-years. The estimated CMR for all-cause mortality was 889 (95% CI 874-904) per 100 000 person-years and for overdose mortality was 211 (203-218) per 100 000 person-years. Among people diagnosed with opioid use disorder before entering prison during 2010-22 (n=6830), provision of opioid agonist treatment was estimated to be associated with reductions in both all-cause mortality (hazard ratio 0·58, 95% CI 0·39-0·85) and overdose mortality (0·51, 0·31-0·82) in the 6 months after leaving prison after adjustment for sociodemographic, prison-related, and clinical characteristics.

INTERPRETATION

In people diagnosed with opioid use disorder released from Norwegian prisons, opioid agonist treatment provided while in prison was a protective factor for both all-cause and overdose mortality at 6 months. Provision of opioid agonist treatment while in prison is crucial in reducing mortality for 6 months after release and should be available to all people in prison who have treatment needs.

FUNDING

South-Eastern Norway Regional Health Authority and the Research Council of Norway.

Sexual abuse during childhood and all-cause mortality into middle adulthood: an Australian cohort study

OBJECTIVE

To compare mortality from all causes, internal causes (eg, cancers, circulatory and respiratory system diseases), and external causes (eg, suicide, accidents, assault) among people who were sexually abused during childhood with mortality for the general population.

DESIGN

Historical cohort study.

SETTING, PARTICIPANTS

2759 people (2201 women, 79.8%) who had experienced medically assessed contact sexual abuse in Victoria while aged 16 years or younger during 1964-1995, as recorded in Victorian Institute of Forensic Medicine records.

MAIN OUTCOME MEASURES

Mortality rate, based on linked National Death Index data (1980-2020), by five-year age group; sex- and age-standardised mortality ratios; comparison of rates with age- and sex-adjusted rates for the general Victorian population (incident rate ratio [IRR]).

RESULTS

We included 115 deaths of people under 50 years of age in our analysis (4.2% of people sexually abused as children; 79 women, 36 men); 56 deaths were attributed to external, 56 to internal causes (cause of death information missing in three cases). In each age group from 15-19 years, the mortality rates for people sexually abused as children were higher than for the general population; age- and sex-standardised all-cause mortality ratios were highest for people aged 25-29 years (men: 16.5; 95% confidence interval [CI], 11.0-22.0; women: 19.2; 95% CI, 14.3-24.2). The age- and sex-adjusted mortality rate for people sexually abused as children was higher than in the general population for all-cause (IRR, 8.25; 95% CI, 5.92-11.5), internal cause (IRR, 5.92; 95% CI, 3.89-9.01), and external cause deaths (IRR, 12.6; 95% CI, 9.61-16.6); the differences in external cause mortality were greater for people who had experienced penetrative (IRR, 14.9; 95% CI, 10.9-20.5) than for those who had experienced non-penetrative sexual abuse as children (IRR, 8.92; 95% CI, 5.35-14.9).

CONCLUSIONS

Sexual abuse during childhood is associated with higher mortality rates into mid-adulthood. Preventing child sexual abuse and intervening early to reduce the damage it inflicts is not only essential for the welfare of the child, but could also help reduce avoidable deaths later in life.

Evaluation of a prison violence prevention program: impacts on violent and non-violent prison infractions

BACKGROUND

Individuals who commit acts of violence in prisons are often placed in highly controlled environments called restrictive housing (i.e., solitary confinement), which can have severe physical and mental health consequences and does not reduce violence. As such, North Carolina prisons have introduced the rehabilitative diversion unit (RDU) to reduce the use of restrictive housing and reduce violence in prison.

METHODS

We evaluated the effect of the RDU on prison infractions. We compared rates of infractions by type (including violent infractions) among men enrolled in the RDU and men who were eligible for the RDU but placed in restrictive housing for control purposes (RHCP). We also evaluated sustained program impacts by comparing the hazard of first infraction among these same two groups of men after program completion, when they had returned to the general prison population. Finally, we compared the hazard of first promotion to a less restrictive custody level (medium custody) when these men had returned to the general prison population.

RESULTS

The primary analytic cohort was made up of 3128 men contributing 897,822 person-days. Adjusted rates of violent infractions were lower in the RDU than in RHCP (adjusted rate ratio: 0.6; 95% CI: 0.4, 1.1). All other categories of infractions, including drug-related infractions, occurred at higher rates during RDU, as compared to RHCP. In analyses of sustained program impacts, for most categories of infractions, there were no differences in the hazard of first infraction post-RDU and post-RHCP. However, the hazard of violent infraction post-RDU was higher (adjusted hazard ratio: 2.1; 95% CI: 1.1, 4.0) than post-RHCP. The hazard of promotion to a less restrictive custody level was higher post-RDU (adjusted hazard ratio: 17.4; 95% CI: 7.2, 42.2) than post-RHCP.

CONCLUSIONS

We found the RDU program may be effective in reducing violence for men enrolled in the program, but that these benefits were not sustained. Continued programming may be a useful tool to transition men from the programmatically intensive environment of the RDU to the general prison population. Additionally, we recommend the expansion of evidence-based treatment for substance use disorder.

The association between drug use and mortality in a norwegian prison cohort: a prospective cohort study

BACKGROUND

Elevated mortality rates are found among people who have experienced incarceration, even long after release from prison. The mechanisms related to this excess mortality are complex products of both individual and situational factors. The aim of this study was to describe all-cause and cause-specific mortality among people with a history of imprisonment, and to examine both individual and situational factors associated with mortality.

METHODS

In this prospective cohort study we used baseline survey data from the Norwegian Offender Mental Health and Addiction (NorMA) study (N = 733) linked with data from the Norwegian Cause of Death Registry during eight years of follow-up (2013-2021).

RESULTS

At end of follow-up, 56 persons (8%) of the cohort were deceased; 55% (n = 31) due to external causes such as overdoses or suicides, and 29% (n = 16) to internal causes such as cancer or lung disease. Having a score > 24 on the Drug Use Disorders Identification Test (DUDIT), indicating likely drug dependence was highly associated with external causes of death (OR 3.31, 95% CI 1.34-8.16), while having a job before baseline imprisonment had a protective effect on all-cause mortality (OR 0.51, ,95% CI 0.28-0.95).

CONCLUSIONS

High DUDIT score at baseline were highly associated with external causes of death, even years after the DUDIT screening was done. Screening incarcerated people using validated clinical tools, such as the DUDIT, together with initiation of appropriate treatment, may contribute to reduced mortality in this marginalized population.

Sex differences in suicide, suicidal ideation, and self-harm after release from incarceration: a systematic review and meta-analysis

PURPOSE

People released from incarceration are at increased risk of suicide compared to the general population. We aimed to synthesise evidence on the incidence of and sex differences in suicide, suicidal ideation, and self-harm after release from incarceration.

METHODS

We searched MEDLINE, EMBASE, PsycINFO, Web of Science and PubMed between 1 January 1970 and 14 October 2021 for suicide, suicidal ideation, and self-harm after release from incarceration (PROSPERO registration: CRD42020208885). We calculated pooled crude mortality rates (CMRs) and standardised mortality ratios (SMRs) for suicide, overall and by sex, using random-effects models. We calculated a pooled incidence rate ratio (IRR) comparing rates of suicide by sex.

RESULTS

Twenty-nine studies were included. The pooled suicide CMR per 100,000 person years was 114.5 (95%CI 97.0, 132.0, I² = 99.2%) for non-sex stratified samples, 139.5 (95% CI 91.3, 187.8, I² = 88.6%) for women, and 121.8 (95% CI 82.4, 161.2, I² = 99.1%) for men. The suicide SMR was 7.4 (95% CI 5.4, 9.4, I² = 98.3%) for non-sex stratified samples, 14.9 for women (95% CI 6.7, 23.1, I² = 88.3%), and 4.6 for men (95% CI 1.3, 7.8, I² = 98.8%). The pooled suicide IRR comparing women to men was 1.1 (95% CI 0.9, 1.4, I² = 82.2%). No studies reporting self-harm or suicidal ideation after incarceration reported sex differences.

CONCLUSION

People released from incarceration are greater than seven times more likely to die by suicide than the general population. The rate of suicide is higher after release than during incarceration, with the elevation in suicide risk (compared with the general population) three times higher for women than for men. Greater effort to prevent suicide after incarceration, particularly among women, is urgently needed.