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Original Research |

Mortality After Prison Release: Opioid Overdose and Other Causes of Death, Risk Factors, and Time Trends From 1999 to 2009

Ingrid A. Binswanger, MD, MPH; Patrick J. Blatchford, PhD; Shane R. Mueller, MSW; and Marc F. Stern, MD
[+] Article, Author, and Disclosure Information

From University of Colorado School of Medicine and Colorado School of Public Health, Aurora, Colorado; Denver Health Medical Center, Denver, Colorado; and University of Washington School of Public Health, Seattle, Washington.

Disclaimer: The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health or the Robert Wood Johnson Foundation.

Acknowledgment: The authors thank Washington State Department of Corrections, especially Kathryn Lundy, RHIT; Mike Evans; and David Daniels, Traci E. Yamashita, MS, Rick Whisenhunt, Melanie Arndt, and Marcy Fulmer for their assistance in the execution of this study; and Jean Kutner, MD, MSPH, and John F. Steiner, MD, MPH, for their thoughtful comments on the design and implementation of this study.

Grant Support: By the National Institute on Drug Abuse of the National Institutes of Health (R21DA031041) and the Robert Wood Johnson Foundation.

Potential Conflicts of Interest: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M13-0979.

Reproducible Research Statement: Study protocol: Not applicable. Statistical code: Portions of the code are available from Dr. Blatchford (e-mail, Patrick.Blatchford@ucdenver.edu). Data set: Not available.

Requests for Single Reprints: Ingrid A. Binswanger, MD, MPH, University of Colorado School of Medicine, Division of General Internal Medicine, Department of Medicine, Mailstop B180, 12631 East 17th Avenue, Aurora, CO 80045; e-mail, ingrid.binswanger@ucdenver.edu.

Current Author Addresses: Dr. Binswanger and Mr. Mueller: University of Colorado School of Medicine, Division of General Internal Medicine, Department of Medicine, Mailstop B180, 12631 East 17th Avenue, Aurora, CO 80045.

Dr. Blatchford: Department of Biostatistics and Informatics, Colorado School of Public Health, Mailstop B119, 13001 East 17th Avenue, Aurora, CO 80045.

Dr. Stern: University of Washington School of Public Health, Department of Health Services, Magnuson Health Sciences Center, 1959 NE Pacific Street, Box 357660, Seattle, WA 98195-7660.

Author Contributions: Conception and design: I.A. Binswanger, M.F. Stern.

Analysis and interpretation of the data: I.A. Binswanger, P.J. Blatchford, M.F. Stern.

Drafting of the article: I.A. Binswanger, P.J. Blatchford.

Critical revision of the article for important intellectual content: S.R. Mueller, M.F. Stern.

Final approval of the article: P.J. Blatchford, S.R. Mueller, M.F. Stern.

Statistical expertise: P.J. Blatchford.

Obtaining of funding: I.A. Binswanger, P.J. Blatchford, M.F. Stern.

Administrative, technical, or logistic support: S.R. Mueller.

Collection and assembly of data: I.A. Binswanger, P.J. Blatchford, S.R. Mueller.

Ann Intern Med. 2013;159(9):592-600. doi:10.7326/0003-4819-159-9-201311050-00005
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Chinese translation

Background: Among former prisoners, a high rate of death has been documented in the early postrelease period, particularly from drug-related causes. Little is known about risk factors and trends in postrelease mortality in the past decade, especially given general population increases in overdose deaths from pharmaceutical opioids.

Objective: To determine postrelease mortality between 1999 and 2009; cause-specific mortality rates; and whether sex, calendar year, and custody factors were risk factors for all-cause, overdose, and opioid-related deaths.

Design: Cohort study.

Setting: Prison system of the Washington State Department of Corrections.

Participants: 76 208 persons released from prison.

Measurements: Identities were linked probabilistically to the National Death Index to identify deaths and causes of death, and mortality rates were calculated. Cox proportional hazards regression estimated the effect of age, sex, race or ethnicity, whether the incarceration resulted from a violation of terms of the person's community supervision, length of incarceration, release type, and calendar year on the hazard ratio (HR) for death.

Results: The all-cause mortality rate was 737 per 100 000 person-years (95% CI, 708 to 766) (n = 2462 deaths). Opioids were involved in 14.8% of all deaths. Overdose was the leading cause of death (167 per 100 000 person-years [CI, 153 to 181]), and overdose deaths in former prisoners accounted for 8.3% of the overdose deaths among persons aged 15 to 84 years in Washington from 2000 to 2009. Women were at increased risk for overdose (HR, 1.38 [CI, 1.12 to 1.69]) and opioid-related deaths (HR, 1.39 [CI, 1.09 to 1.79]).

Limitation: The study was done in only 1 state.

Conclusion: Innovation is needed to reduce the risk for overdose among former prisoners.

Primary Funding Source: National Institute on Drug Abuse and the Robert Wood Johnson Foundation.


Grahic Jump Location

Mortality rate, by week since release, for overdose and all other (nonoverdose) causes of death.

Grahic Jump Location




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