Correspondence
Mortality after Release from Prison
N Engl J Med 2007; 356:1785-1787April 26, 2007
- Article
To the Editor:
In the article by Binswanger and colleagues (Jan. 11 issue),1 the mortality among former prisoners in Washington State — 777 deaths per 100,000 person-years — is striking. The investigators followed released inmates for a mean period of 1.9 years. The mortality soared immediately after release, and continued to be high after that period. Overall, the relative risk of death was 3.5 times that among other Washington residents in a reference group adjusted for age, sex, and race.
We studied longer-term mortality among 273 inmates (mean age, 43 years) admitted to the combined jail and prison system of Rhode Island in 1992. National Death Index matches showed that 9.9% of the inmates died over a follow-up period of 6.5 years (mortality, 1598 deaths per 100,000 person-years; mean age at death, 45 years). All the deaths were thought to have occurred among persons who had been released from custody. Drug overdose, human immunodeficiency virus (HIV) infection and AIDS, and hepatitis were the leading causes of death.2 The standard mortality ratio for those in our study cohort as compared with a contemporaneous, age-adjusted male reference population in Rhode Island was 4.5.3
Binswanger et al. assert that mortality data “could focus preventive efforts” among ex-prisoners. Would longer follow-up periods reveal more deaths due to hepatitis? To understand more fully how prisoners' lives, and thus their preventive health needs, are different from those of persons who have never been incarcerated, a follow-up period longer than that of our 6.5-year pilot study is needed.
3 ReferencesAnne C. Spaulding, M.D., M.P.H.
Emory University, Atlanta, GA 30322
aspauld@emory.edu Scott A. Allen, M.D.
Miriam Hospital, Providence, RI 02906Andrew Stone, M.D., M.P.H.
Brown University, Providence, RI 029081
Binswanger IA ,Stern MF ,Deyo RA , et al. Release from prison -- a high risk of death for former inmates. N Engl J Med 2007;356:157-165
Full Text | Web of Science | Medline2
Allen S, Stone A, Spaulding A. Death rate and causes of mortality in Rhode Island inmates. Presented at the 26th National Commission on Correctional Health Care National Conference, Nashville, October 19–23, 2002.
3
Compressed mortality data file for the years 1979-1998 with ICD 9 codes. Atlanta: Centers for Disease Control and Prevention. (Accessed April 5, 2007, at http://wonder.cdc.gov/mortSQL.html.)
To the Editor:
Binswanger et al. report an extraordinary risk of death due to drug overdose in the weeks after release from prison; this finding is consistent with earlier reports.1 Although cocaine was a leading cause of death in this study, opiate-related deaths usually predominate and have been the focus of efforts to develop effective preventive interventions. Maintenance treatment with methadone or buprenorphine, the latter of which can now be prescribed by general practitioners, has been proved to decrease deaths due to opiate overdose.2,3 Training of drug-using peers in rescue breathing may also prevent death.4 Departments of health in numerous localities, including Baltimore, San Francisco, and New Mexico, prescribe naloxone for drug-using peers with hundreds of saved lives reported each year, although there have been no controlled trials.5 New York State law now encourages the prescription of naloxone and grants recipients immunity against liability for lay administration in the case of a suspected overdose. These interventions should be seriously considered by prerelease programs in prisons as well as by medical providers in the general community.
5 ReferencesPhillip O. Coffin, M.D.
Columbia University Medical Center, New York, NY 10032
poc2@columbia.edu 1
Seaman SR ,Brettle RP ,Gore SM . Mortality from overdose among injecting drug users recently released from prison: database linkage study. BMJ 1998;316:426-428
CrossRef | Web of Science | Medline2
Caplehorn JR ,Dalton MS ,Haldar F ,Petrenas AM ,Nisbet JG . Methadone maintenance and addicts' risk of fatal heroin overdose. Subst Use Misuse 1996;31:177-196
CrossRef | Web of Science | Medline3
Gueye PN ,Megarbane B ,Borron SW , et al. Trends in opiate and opioid poisonings in addicts in north-east Paris and suburbs, 1995-99. Addiction 2002;97:1295-1304
CrossRef | Web of Science | Medline4
Dietze P ,Cantwell K ,Burgess S . Bystander resuscitation attempts at heroin overdose: does it improve outcomes? Drug Alcohol Depend 2002;67:213-218
CrossRef | Web of Science | Medline5
Sporer KA ,Kral AH . Prescription naloxone: a novel approach to heroin overdose prevention. Ann Emerg Med 2007;49:172-177
CrossRef | Web of Science | Medline
To the Editor:
The article by Binswanger and colleagues has implications not only for former inmates (many of whom have an addiction) but also more broadly for persons with substance dependence. We recently reported a high risk of death among young adults after release from an inpatient detoxification program. These deaths were primarily from overdose (>40%),1 a condition with underappreciated public health significance.
In the United States, poisoning (the surveillance term that includes overdose) has quietly risen to the second leading cause of death due to injury, with 30,308 deaths in 2004.2 Unlike deaths related to motor-vehicle crashes, firearms, suicide, and HIV infection, deaths due to poisoning have been steadily increasing (by 54% from 1999 to 2004). The growing misuse of prescription pain relievers by young people3 — indeed, new users now outnumber marijuana initiates — heightens concern that deaths from overdose will continue to mount. It is striking that the full scope of this “national epidemic of drug poisoning deaths”4 is largely unknown. Comprehensive research and service strategies are needed to address overdose prevention and fragmented systems of health care that do not bridge life transitions such as departure from an inpatient addiction-treatment setting or discharge from prison.
4 ReferencesJames D. Wines, Jr., M.D., M.P.H.
McLean Hospital, Belmont, MA 02478
jwines@hms.harvard. edu Richard Saitz, M.D., M.P.H.
Jeffrey H. Samet, M.D., M.P.H.
Boston University Medical Center, Boston MA, 021181
Saitz R ,Gaeta J ,Cheng DM ,Richardson JM ,Larson MJ ,Samet JH . Risk of mortality during four years after substance detoxification in urban adults. J Urban Health 2007;84:272-282http://www.springerlink.com/content/f805r24587886155/?p=3a5ca5267366488c9801f55508c6f419&pi=0
CrossRef | Web of Science | Medline2
Web-based Injury Statistics Query and Reporting System (WISQARS). Atlanta: Centers for Disease Control and Prevention, 2007. (Accessed April 5, 2007, at http://www.cdc.gov/ncipc/wisqars/default.htm.)
3
Misuse of prescription drugs. Rockville, MD: Substance Abuse and Mental Health Services Administration (SAMHSA), Office of Applied Studies. (Accessed April 5, 2007, at http://www.oas.samhsa.gov/prescription/toc.htm.)
4
Paulozzi LJ ,Budnitz DS ,Xi Y . Increasing deaths from opioid analgesics in the United States. Pharmacoepidemiol Drug Saf 2006;15:618-627
CrossRef | Web of Science | Medline
Author/Editor Response
With regard to the comments by Spaulding et al., the high mortality rate among Rhode Island jail and prison inmates suggests that our results from Washington State may be applicable to other states and correctional settings. With a longer follow-up than that of our 4.5-year cohort study, we would probably have ascertained more deaths due to hepatitis C and HIV infection, given the natural history of these infections. Interventions geared toward reducing the risk of death in the immediate period after release from prison may differ from those geared toward reducing longer-term mortality. Reducing both short-term and long-term mortality among former inmates will require coordination among the correctional, community, public health, drug treatment, and medical care systems.
Coffin comments on the risk of opiate-related deaths after release from prison and approaches to preventing these deaths. The evaluation of maintenance treatment with methadone or buprenorphine as a means of reducing overdose-related deaths during the transition from prison to the community, after persons have already undergone detoxification from opiates in prison, is warranted. The distribution of naloxone and training of drug users in rescue breathing are both promising interventions to reduce the risk associated with overdose among active users of opiates. How to use these interventions to reduce the risk among former inmates still needs to be determined. Enhancing former inmates' access to a range of effective forms of drug treatment and overdose-prevention strategies would be an excellent approach to reducing their risk of overdose.
We too were surprised about the high rate of death from cocaine and psychostimulants as compared with deaths from opiates. Our findings underscore the need to develop, test, and implement strategies to prevent overdoses related to the use of cocaine and methamphetamine. An understanding of the mechanisms of toxicity related to these agents and epidemiologic data on the characteristics associated with resultant deaths could help guide such approaches.
Wines et al. put our results showing a high risk of death after release from prison in the context of the rising rates of overdose as a cause of death in the United States. Prompted by their letter, a further analysis of our data showed that crude mortality rates from overdose did increase over time. Given the high vulnerability of persons who use substances during transitional periods, improving transitions between health care settings — particularly among correctional, community, and drug-treatment settings — is critically important.
Ingrid Binswanger, M.D., M.P.H.
University of Colorado at Denver, Denver, CO 80262
ingrid.binswanger@uchsc. edu Marc F. Stern, M.D., M.P.H.
Washington State Department of Corrections, Tumwater, WA 98504Joann G. Elmore, M.D., M.P.H.
University of Washington, Seattle, WA 98104- Citing Articles (2)
Citing Articles
1
Elizabeth L. C. Merrall, Azar Kariminia, Ingrid A. Binswanger, Michael S. Hobbs, Michael Farrell, John Marsden, Sharon J. Hutchinson, Sheila M. Bird. (2010) Meta-analysis of drug-related deaths soon after release from prison. Addiction 105:9, 1545-1554
CrossRef2
Manop Kanato. (2008) Drug use and health among prison inmates. Current Opinion in Psychiatry 21:3, 252-254
CrossRef
