Full length articleResumption of injecting drug use following release from prison in Australia
Introduction
Globally, illicit and injecting drug users are over-represented in correctional settings (Fazel et al., 2006). In Australia, around two-thirds of prisoners report illicit drug use in the year prior to imprisonment and an estimated 45% have a history of injecting drug use (IDU; Australian Institute of Health and Welfare, 2015). Research findings show that imprisonment often fails to have any long-term beneficial impact on substance use trajectories, instead serving as a temporary interruption to use (DeBeck et al., 2009, Evans et al., 2009), as substance use is usually reduced or ceased during imprisonment. Incarceration is often considered an opportunity for the rehabilitation of prisoners with a history of problematic substance use. However, incarceration may increase the risk of return to IDU among those who cease injection prior to imprisonment (Genberg et al., 2015), and decrease the likelihood of IDU cessation following imprisonment in the longer term (Bruneau et al., 2004, DeBeck et al., 2009, Evans et al., 2009). Incarceration may also decrease access to the tools that support cessation, such as community participation (DeBeck et al., 2009). Collectively, these findings question the individual and societal benefits of incarcerating individuals whose non-violent offences are attributable to substance use.
Prisoners also experience high rates of co-occurring health and socio-economic disadvantage prior to incarceration including unemployment, housing instability, mental disorder, infectious and chronic disease and other social and health disparities (Baldry et al., 2006, Fazel and Baillargeon, 2011, Larney et al., 2013, Cutcher et al., 2014). Among those with a history of IDU, these factors may increase the likelihood of resumption of IDU following release from prison (Binswanger et al., 2012). In addition, the difficulties of community integration after release from prison (Mallik-Kane and Visher, 2008, Visher et al., 2011), and the challenges posed by return to drug using networks (Binswanger et al., 2012, Malouf et al., 2012) may exacerbate the risk of IDU resumption. Release from prison has been associated with engaging in high-risk IDU behaviour, with some studies reporting a rapid return to substance use following release from prison (Shewan et al., 2001, Kinner, 2006, Evans et al., 2009, Milloy et al., 2009, Binswanger et al., 2012), unemployment (Visher et al., 2011), homelessness (Evans et al., 2009), disruption or restricted access to drug (Dolan et al., 2005, Stallwitz and Stöver, 2007, Fu et al., 2013) and other medical treatment programs (Milloy et al., 2011), and recidivism (Håkansson and Berglund, 2012, Kirwan et al., 2015). For ex-prisoners, IDU carries a high risk of fatal (Merrall et al., 2010) and non-fatal (Winter et al., 2015) overdose, infectious disease acquisition and transmission (Dolan et al., 2005), and other poor health and social outcomes (Kinner, 2006, Mallik-Kane and Visher, 2008, Swan, 2015). There is increasingly compelling evidence that improving health outcomes for ex-prisoners have considerable individual and societal benefits (Kinner and Wang, 2014).
Longitudinal studies examining post-release health outcomes are scarce and often suffer from high rates of attrition, potentially resulting in biased estimation of substance use and other health and social outcomes. Critically, there is a gap in the literature on the rate of return to IDU following release from prison, and the factors associated with accelerated drug use resumption trajectories. It is important to establish the rate of IDU resumption to help tailor appropriate interventions and time their delivery accordingly. It is well established that the risk of overdose mortality is greatest in the first few weeks following prison release (Merrall et al., 2010), indicating that resumption of risky substance use in the community occurs swiftly for at least a subset of ex-prisoners. However, the relationship between release from prison and IDU resumption is dynamic and complex; many social, structural and interpersonal factors may influence return to IDU and the rate at which it occurs. In this study, we measured the rate of IDU resumption following release from prison in a cohort of ex-prisoners recruited in the weeks preceding release from custody in Queensland, Australia, and identified factors associated with time to IDU resumption.
Section snippets
Study design and setting
The Passports study was a multi-site, single-blinded, randomised controlled trial of a case-management re-entry intervention for sentenced adult prisoners in the state of Queensland, Australia. The study methods are described in detail elsewhere (Kinner et al., 2013). Baseline interviews were conducted within six weeks of expected release from prison and before randomisation in the seven prisons from which the majority of sentenced prisoners in the State were released. Participants were
Sample characteristics
A total of 533 eligible participants completed at least one follow-up interview (Fig. 1) and were included in analyses; 458 (77.1%) completed FU1 (median days since release = 33; IQR = 31–38), 434 (73.1%) completed FU2 (median days = 98; IQR = 94–121) and 404 (68.0%) completed FU3 (median days = 207; IQR = 187–247). Compared with those included in the analyses, participants lost to follow-up (n = 98) were significantly less likely to have been released on parole from their index incarceration (χ2 = 12.68, df =
Discussion
Our results show that prisoners with a history of IDU often recommence IDU in the community soon after release from prison with nearly one quarter of participants reporting IDU within one month following release and two fifths reporting IDU over approximately 6 months following release. Of those who reported IDU in the community after release, a significant proportion never ceased IDU while imprisoned, and this was the strongest predictor of time to IDU resumption following release.
To our
Role of funding source
This work was supported by Australian National Health and Medical Research Council (NHMRC) Strategic Award#409966 and the Centre for Research Excellence on Injecting Drug Use (CREIDU) #1001144. RW is supported by NHMRC Postgraduate Scholarship#603756 and CREIDU. JY is supported by a Melbourne University International Research Scholarship, MS is supported by NHMRC Career Development Fellowship#1090445, PA is supported by CREIDU, MH is supported by NHMRC Principal Research Fellowship#1112297, SK
Contributors
SK designed the Passports study; RW, JY, MS, PA, MH and SK devised the sub-study aims and approach. PA and JY advised on statistical approach; JY conducted primary analyses. RW wrote the manuscript. All authors contributed to multiple drafts and approved the final manuscript.
Conflict of interest
None to declare.
Acknowledgements
The authors wish to thank Queensland Corrective Services and the Passports study interview team for assistance with data collection. The views expressed herein are solely those of the authors, and in no way reflect the views or policies of Queensland Corrective Services. We wish to thank the Passports study participants for sharing their stories. Finally, we wish to acknowledge the late Professor Konrad Jamrozik for his immense contribution to the conception, development and implementation of
References (49)
- et al.
Interpreting scores on the Kessler psychological distress scale (K10)
Aust. N. Z. J. Public Health
(2001) - et al.
Treatment during transition from prison to community and subsequent illicit drug use
J. Subst. Abuse Treat.
(2005) - et al.
Poor health and social outcomes for ex‐prisoners with a history of mental disorder: a longitudinal study
Aust. N. Z. J. Public Health
(2014) - et al.
Predictors of injection drug use cessation and relapse in a prospective cohort of young injection drug users in San Francisco, CA (UFO Study)
Drug Alcohol Depend.
(2009) - et al.
The health of prisoners
Lancet
(2011) - et al.
Forced withdrawal from methadone maintenance therapy in criminal justice settings: a critical treatment barrier in the United States
J. Subst. Abuse Treat.
(2013) - et al.
Randomised controlled trial of a service brokerage intervention for ex-prisoners in Australia
Contemp. Clin. Trials
(2013) - et al.
Self-control and jail inmates' substance misuse post-release: mediation by friends' substance use and moderation by age
Addict. Behav.
(2012) - et al.
The impact of substitution treatment in prisons—a literature review
Int. J. Drug Policy
(2007) - et al.
Incidence and predictors of non-fatal drug overdose after release from prison among people who inject drugs in Queensland
Aust. Drug Alcohol Depend.
(2015)