Elsevier

Drug and Alcohol Dependence

Volume 168, 1 November 2016, Pages 104-111
Drug and Alcohol Dependence

Full length article
Resumption of injecting drug use following release from prison in Australia

https://doi.org/10.1016/j.drugalcdep.2016.08.640Get rights and content

Highlights

  • 41% of 533 ex-prisoners with IDU history resumed IDU over 6 months after prison.

  • The highest incidence of IDU resumption occurred within 1 month following release.

  • Discrete-time survival analysis was used to examine predictors of IDU resumption.

  • IDU in prison, post-release unemployment and shorter prison sentences predicted IDU.

  • Release on parole initially reduced IDU risk but the effect decayed over time.

Abstract

Introduction

Ex-prisoners with a history of injecting drug use (IDU) experience disproportionate drug-related harm. Rapid resumption of substance use following prison release is common and evidenced in high rates of overdose mortality. However, few studies have documented the rate of IDU resumption following prison release or identified risk factors for relapse.

Methods

Structured interviews were conducted with 533 adults with a history of IDU in Queensland, Australia prior to release from prison and approximately 1, 3 and 6 months post-release. Incidence of self-reported IDU resumption was calculated overall and for each follow-up interval. Risk factors associated with time to resumption of IDU were estimated using discrete-time survival analysis.

Results

IDU resumption was reported by 41% of participants during a median of 98 days of follow-up (IQR = 94–121), an overall crude incidence of 1.06 per person-year. The highest rate was observed in the first month (23%; crude incidence 2.24 per person-year). In adjusted discrete-time survival analyses, being unemployed at the previous interview (AHR = 1.59; 95%CI:1.10–2.30), shorter incarceration (≤90 days vs. >365 days; AHR = 2.20; 95%CI:1.33–3.65), and IDU during the index incarceration (AHR = 2.80; 95%CI:1.92–4.09) were significantly associated with time to IDU resumption; parole was protective (AHR = 0.66; 95%CI:0.47–0.92).

Conclusions

Evidence-based efforts to prevent IDU in prison and IDU resumption after release are important for both prisoner and public health. Enhancing opportunities for employment and capitalising on the short-term benefits of parole for ex-prisoners may delay resumption of IDU after release from prison. These strategies should complement rather than replace harm reduction efforts for this high-risk population.

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

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