Non-fatal overdose among adult prisoners with a history of injecting drug use in two Australian states

https://doi.org/10.1016/j.drugalcdep.2013.06.001Get rights and content

Abstract

Background

Recently released prisoners are at markedly increased risk of death and drug-related causes predominate. Non-fatal overdose (NFOD) is considerably more common than fatal overdose, but has received relatively little research attention and most studies of NFOD in this population have suffered from small samples of unknown representativeness. This study aimed to estimate the prevalence and correlates of lifetime NFOD among prisoners in NSW and Queensland.

Methods

Cross-sectional surveys of adult prisoners in two Australian states: New South Wales (n = 972) and Queensland (n = 1316). Use of similar measures and methods in the two states made direct comparison of findings possible.

Results

In both NSW and Queensland, 23% of participants reported a lifetime history of NFOD and prisoners with a history of injecting drug use were significantly more likely to report lifetime NFOD. The lifetime prevalence of NFOD among prisoners with a history of injecting drug use was significantly higher in NSW than in Queensland (44% vs. 35%; p < 0.01). Independent correlates of lifetime NFOD were similar across the two states and included ever attempting suicide, ever injecting heroin, and ever injecting opioids.

Conclusions

The risk of NFOD among prisoners with a history of injecting drug use is high. An understanding of the risk factors for NFOD in this population can inform targeted, evidence-based interventions to reduce this risk.

Introduction

Recently released prisoners are at markedly increased risk of preventable death, primarily due to drug overdose and suicide (Kinner et al., 2013a, Kinner et al., 2013b, Merrall et al., 2010, Zlodre and Fazel, 2012). For example, in a study of 48,771 sentenced prisoners in England and Wales, Farrell and Marsden (2008) found that in the first week after release from custody male prisoners were 29.4 times more likely to die, and women were 68.9 times more likely to die, than sex- and age-matched community peers. Over 95% of these deaths were attributed to drugs. Similarly, a large Australian study of 85,203 adults with a history of incarceration found that age- and sex-standardised mortality ratios were substantially elevated for drug-related deaths (Kariminia et al., 2007). Although a number of studies have examined drug-related death among ex-prisoners, the limitations associated with routinely collected data (e.g., administrative data contain few potential predictor variables, and a lack of detail on circumstances surrounding the death) mean that few risk factors have been identified, hampering efforts to inform preventive interventions (Kinner, 2010).

Community studies in Australia indicate that non-fatal overdose (NFOD) is considerably more common than fatal overdose (Darke et al., 2003) and is associated with substantial morbidity, particularly pressure injuries and pulmonary complications (Warner-Smith et al., 2002). Understanding who is most at risk of NFOD is important to inform efforts to prevent both non-fatal (Darke, 2008) and fatal overdose in high risk groups such as ex-prisoners, yet NFOD has received relatively little research attention (Strang, 2002).

A number of studies have identified a history of recent incarceration as a risk factor for NFOD in community recruited cohorts (Kerr et al., 2007, Seal et al., 2001, Yin et al., 2007), however few have examined NFOD among prisoners or ex-prisoners. Thus, despite calls from the World Health Organisation (WHO, 2010) and others to provide evidence-based support for those at greatest risk of drug-related harm after release from prison, it remains unclear who among this already at-risk population is most likely to experience an overdose post-release (Kinner et al., 2012). Given evidence that the experience of NFOD is associated with an increased risk of subsequent non-fatal and fatal overdose (Coffin et al., 2007, Darke et al., 2011, Kinner et al., 2012, Stoove et al., 2009), understanding who is most at risk of another overdose (non-fatal or fatal) after release from custody can assist in targeting preventive interventions.

Among people who inject drugs, studies in community settings have identified a number of risk factors for NFOD including homelessness, a history of multiple arrests and/or imprisonments, longer time in prison, binge drug use and/or higher frequency of injecting, street injecting, longer history of opiate use, and polysubstance use (Coffin et al., 2007, Seal et al., 2001, Sergeev et al., 2003, Yin et al., 2007). Older age and enrolment in methadone maintenance treatment seem to be protective (Coffin et al., 2007, Kerr et al., 2007, Seal et al., 2001). Others have found that the risk of NFOD is compounded by poor mental health, particularly depression and suicidal behaviour (Rossow and Lauritzen, 1999, Tobin and Latkin, 2003). While the evidence is not as strong, it has been argued that systemic disease, particularly smoking-related lung disease and liver dysfunction associated with hepatitis C, may also increase the risk of overdose (Warner-Smith et al., 2001). A recent longitudinal study of 2,515 community-recruited illicit drug users in Vancouver (Kinner et al., 2012) found that while recent incarceration was associated with more than twice the odds of NFOD, other risk factors for NFOD in recently released prisoners were similar to those for illicit drug users who had not been incarcerated recently. Irrespective of recent incarceration, independent risk factors for NFOD included daily use of heroin, benzodiazepines, cocaine or methamphetamine; binge drug use; public injecting; and previous NFOD.

Many studies of NFOD have suffered from small samples of unknown representativeness, limiting the generalisability of the findings. Given jurisdictional differences in drug markets, structural factors and cultural context, it is unclear whether the findings from one setting can be applied to others. Using data from two large samples of prisoners in Australia (New South Wales and Queensland), the aims of this study were to (1) estimate the prevalence of lifetime NFOD in adult prisoners and in those with a lifetime history of injecting drug use (IDU), (2) identify independent correlates of NFOD in prisoners with a history of IDU, and (3) compare the prevalence and correlates of NFOD among prisoners in New South Wales and Queensland.

Section snippets

Methods

Data for the present study come from cross-sectional surveys of adult prisoners in two Australian states: New South Wales (NSW) and Queensland. NSW and Queensland account for 52% of the total Australian resident population (ABS, 2012a) and 52% of the total daily prisoner population (N = 29,383) (ABS, 2012b).

Results

Of the 1166 inmates randomly selected in NSW and invited to participate, 996 agreed, giving a recruitment fraction of 85.4%. Of the 10,931 prisoners released from Queensland prisons during the study period, 1,646 (16%) were assessed as eligible and approached and of these, 80.5% consented to participate. This paper utilises data from 972 participants for NSW and 1316 participants from Queensland, where a valid response was provided to questions about lifetime non-fatal overdose (yes/no) and

Discussion

We examined the prevalence and correlates of NFOD in large samples of prisoners from two Australian states. Similar measures and methods provided a unique opportunity to compare findings across settings. Around a quarter of prisoners in both states reported experiencing at least one NFOD in their lifetime and as expected, these overdoses occurred primarily among IDU. The prevalence of lifetime NFOD among prisoners with a history of IDU in NSW (44%) and Queensland (35%) is comparable with

Role of funding source

Nothing declared.

Contributors

Author Moore conducted the statistical analyses with the NSW data, and wrote the first draft of the manuscript. Author Winter conducted the statistical analyses with the Queensland data. Authors Indig and Greenberg contributed to the design of the 2009 Inmate Health Survey and wrote the protocol. Author Kinner designed the Passports study and wrote the protocol. All authors contributed to the design of the study, provide input to drafts and have approved the final manuscript.

Conflict of interest

No

Acknowledgements

The authors would like to acknowledge Shalin Kumar (Clinical Co-ordinator), Belinda Border (Hunter New England Population Health), the Inmate Health Survey investigator team, Corrective Services NSW, and Professor Tony Butler (original development of the Inmate Health Survey). Funding for the Inmate Health Survey was provided by NSW Health and Justice & Forensic Mental Health Network. The authors also acknowledge Queensland Corrective Services for support during data collection in Queensland,

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