Preventable Deaths Among Ex-Prisoners

Recent figures suggest that former prisoners have “alarmingly high” rates of death from alcohol and drug misuse. Raised mortality rates previously have been found among ex-prisoners, but the potential risk factors for these high rates has not been investigated in depth.

In the U.S., the ex-prisoner population is estimated as 5.4 million people, who account for about 12 percent of roughly 250,000 deaths from external causes every year.

Professor Seena Fazel and colleagues at Oxford University, UK, analyzed the causes of deaths among all 47,326 prisoners released from prison in Sweden between 2000 and 2009. Among the prisoners for whom figures are available, 42 percent of the men had a psychiatric diagnosis, as did 64 percent of the women. Prevalence of alcohol and drug use was “high.”

About six percent of the prisoners died during the five years after leaving prison. Overall, 44 percent of these deaths were due to accidents and suicides. About a third (34 percent) of the deaths among men and half (50 percent) of the deaths among women were linked to alcohol and substance misuse.

Those with a previous history of drug and alcohol misuse had a particularly high risk of death after release, which persisted for years afterward. However, other psychiatric disorders including schizophrenia, bipolar disorder, and depression did not appear to increase the post-release mortality rate.

Substance use disorders were also an independent risk factor for death by accidents or suicide, causing an estimated 42 percent of these deaths in men and 70 percent in women. Full details are published in The Lancet Psychiatry.

According to the authors, “Our study is the first to investigate the effect of substance use disorders and other psychiatric disorders on mortality after prison release, while taking into account both measured (sociodemographic and criminological) and unmeasured (familial) confounding factors.

We also investigated individual causes of death, and noted that non-traffic accidents and suicide contributed to a large proportion of external-cause deaths.”

They believe “[I]nterventions to address substance use disorders could substantially decrease the burden of excess mortality in people released from prison, but might need to be provided beyond the immediate period after release.”

Many clinical guidelines focus on transitions, they point out, but “our findings suggest that this alone might not lead to large reductions in mortality of people released from prisons, and guidelines for the clinical care of these individuals need to be reviewed.”

Fazel said, “Our striking findings show the potential for preventive and therapeutic programs to significantly reduce the number of deaths from alcohol and substance misuse, which are highly prevalent among the 30 million people worldwide who spend time in prison every year.

“In England and Wales, we estimate that around three percent of all deaths from external causes can be prevented if alcohol and substance use disorders were fully treated in released prisoners. In the U.S., where there are much higher incarceration rates, about nine percent of deaths from external causes are potentially preventable.”

Professor Fazel added that, “Although alcohol abuse is as common as drug abuse, and the high mortality risks following release are similar, it does not receive the same level of attention or funding.” Prevention efforts “could not only reduce mortality in people released from custody, but also improve both public health and safety,” he said.

Sarah Wakeman, M.D., from Harvard Medical School and Josiah Rich, M.D., M.P.H., from Brown University wrote a commentary on the study. They said, “The two weeks after release from prison have been shown to be associated with a substantial increase in mortality, especially from overdose.

“Addiction is a treatable disease and decades of scientific evidence support the efficacy of treatment to improve clinical outcomes, save lives, and reduce societal costs. The withholding of evidence-based treatment for prisoners is arguably unethical and certainly unwise.

“In the USA, correctional facilities are mandated by the Supreme Court to provide medical care that meets the community standard. And yet, within state prisons people with drug use disorders largely go without care. Of these people, only 0.8 percent receive detoxification services, 0.3 percent receive maintenance pharmacotherapy, 6.5 percent receive counselling by a professional, and 9.5 percent receive treatment in a residential facility.

“The absence of care in this deeply affected population translates into high costs to society and the communities that these individuals return to. As the study shows, these costs also translate into avoidable deaths from a treatable illness.”

References

Chang, Z. et al. Substance use disorders, psychiatric disorders, and mortality after release from prison: a nationwide longitudinal cohort study. The Lancet Psychiatry, 22 April 2015 doi: 10.1016/S2215-0366(15)00088-7
The Lancet

Wakeman, S. E., Richemail, J. D. et al. Substance use disorders and avoidable mortality after prison. The Lancet Psychiatry, 22 April 2015 doi: 10.1016/S2215-0366(15)00125-X
The Lancet