Shane R. Mueller

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

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 persons 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.

A Review of Opioid Overdose Prevention and Naloxone Prescribing: Implications for Translating Community Programming Into Clinical Practice

BACKGROUND As physicians have increased opioid prescribing, overdose deaths from pharmaceutical opioids have substantially increased in the United States. Naloxone hydrochloride (naloxone), an opioid antagonist, is the standard of care for treatment of opioid induced respiratory depression. Since 1996, community-based programs have offered overdose prevention education and distributed naloxone for bystander administration to people who use opioids, particularly heroin. There is growing interest in translating overdose education and naloxone distribution (OEND) into conventional medical settings for patients who are prescribed pharmaceutical opioids. For this review, we summarized and classified existing publications on overdose education and naloxone distribution to identify evidence of effectiveness and opportunities for translation into conventional medical settings. METHODS For this review, we searched English language PubMed for articles on naloxone based on primary data collection from humans, including feasibility studies, program evaluations, surveys, qualitative studies, and studies comparing the effectiveness of different routes of naloxone administration. We also included cost-effectiveness studies. RESULTS We identified 41 articles that represented 5 categories: evaluations of OEND programs, effects of OEND programs on experiences and attitudes of participants, willingness of medical providers to prescribe naloxone, comparisons of different routes of naloxone administration, and the cost-effectiveness of naloxone. CONCLUSIONS Existing research suggests that people who are at risk for overdose and other bystanders are willing and able to be trained to prevent overdoses and administer naloxone. Counseling patients about the risks of opioid overdose and prescribing naloxone is an emerging clinical practice that may reduce fatalities from overdose while enhancing the safe prescribing of opioids.

Overdose Education and Naloxone for Patients Prescribed Opioids in Primary Care: A Qualitative Study of Primary Care Staff

ABSTRACTBACKGROUNDThe rate of fatal unintentional pharmaceutical opioid poisonings has increased substantially since the late 1990s. Naloxone is an effective opioid antidote that can be prescribed to patients for bystander use in the event of an overdose. Primary care clinics represent settings in which large populations of patients prescribed opioids could be reached for overdose education and naloxone prescription.OBJECTIVEOur aim was to investigate the knowledge, attitudes and beliefs about overdose education and naloxone prescription among clinical staff in primary care.DESIGNThis was a qualitative study using focus groups to elucidate both clinic-level and provider-level barriers and facilitators.SETTINGTen primary care internal medicine, family medicine and infectious disease/HIV practices in three large Colorado health systems.METHODSA focus group guide was developed based on behavioral theory. Focus group transcripts were coded for manifest and latent meaning, and analyzed for themes using a recursive approach that included inductive and deductive analysis.RESULTSThemes emerged in four content areas related to overdose education and naloxone prescription: knowledge, barriers, benefits and facilitators. Clinical staff (N = 56) demonstrated substantial knowledge gaps about naloxone and its use in outpatient settings. They expressed uncertainty about who to prescribe naloxone to, and identified a range of logistical barriers to its use in practice. Staff also described fears about offending patients and concerns about increased risk behaviors in patients prescribed naloxone. When considering naloxone, some providers reflected critically and with discomfort on their own opioid prescribing. These barriers were balanced by beliefs that prescribing naloxone could prevent death and result in safer opioid use behaviors.LIMITATIONSFindings from these qualitative focus groups may not be generalizable to other settings.CONCLUSIONIn addition to evidence gaps, logistical and attitudinal barriers will need to be addressed to enhance uptake of overdose education and naloxone prescription for patients prescribed opioids for pain.

Prison tobacco control policies and deaths from smoking in United States prisons: population based retrospective analysis

Objective To determine the mortality attributable to smoking and years of potential life lost from smoking among people in prison and whether bans on smoking in prison are associated with reductions in smoking related deaths. Design Analysis of cross sectional survey data with the smoking attributable mortality, morbidity, and economic costs system; population based time series analysis. Setting All state prisons in the United States. Main outcome measures Prevalence of smoking from cross sectional survey of inmates in state correctional facilities. Data on state prison tobacco policies from web based searches of state policies and legislation. Deaths and causes of death in US state prisons from the deaths in custody reporting program of the Bureau of Justice Statistics for 2001-11. Smoking attributable mortality and years of potential life lost was assessed from the smoking attributable mortality, morbidity, and economic costs system of the Centers for Disease Control and Prevention. Multivariate Poisson models quantified the association between bans and smoking related cancer, cardiovascular and pulmonary deaths. Results The most common causes of deaths related to smoking among people in prison were lung cancer, ischemic heart disease, other heart disease, cerebrovascular disease, and chronic airways obstruction. The age adjusted smoking attributable mortality and years of potential life lost rates were 360 and 5149 per 100 000, respectively; these figures are higher than rates in the general US population (248 and 3501, respectively). The number of states with any smoking ban increased from 25 in 2001 to 48 by 2011. In prisons the mortality rate from smoking related causes was lower during years with a ban than during years without a ban (110.4/100 000 v 128.9/100 000). Prisons that implemented smoking bans had a 9% reduction (adjusted incidence rate ratio 0.91, 95% confidence interval 0.88 to 0.95) in smoking related deaths. Bans in place for longer than nine years were associated with reductions in cancer mortality (adjusted incidence rate ratio 0.81, 95% confidence interval 0.74 to 0.90). Conclusions Smoking contributes to substantial mortality in prison, and prison tobacco control policies are associated with reduced mortality. These findings suggest that smoking bans have health benefits for people in prison, despite the limits they impose on individual autonomy and the risks of relapse after release.

Risk Factors for Cervical Cancer in Criminal Justice Settings

BACKGROUND Women in criminal justice settings have an increased prevalence of cervical cancer compared with the general population. However, little is known about abnormal cervical cancer screening results among women in jail and community-based criminal justice settings. Thus, the aims of this study were to compare the prevalence of self-reported abnormal Papanicolou (Pap) test results in women in jail and under community criminal justice supervision and to examine factors associated with abnormal Pap tests in these criminal justice settings. METHODS We analyzed data from two cross-sectional surveys of women in jails and community corrections in two Southern cities (n=380) about their history of abnormal Pap tests and risk factors for cervical cancer. Univariate analyses (analysis of variance [ANOVA] and chi-square) and a binary logistic regression analysis were conducted to test associations between a history of abnormal Pap testing and factors known to be associated with cervical cancer. RESULTS Nearly half of the women surveyed (n=163, 43%) reported ever having an abnormal Pap test. There was a high prevalence of risk factors for cervical cancer among women with and without an abnormal Pap test. After controlling for age and race, there were significant associations between an abnormal Pap test and inconsistent use of barrier protection (odds ratio [OR] 2.01, 95% confidence interval [CI] 1.18-3.43), having a history of gynecologic infections (OR 1.68, 95% CI 1.05-2.67), and having a history of sexually transmitted diseases (OR 1.92, 95% CI 1.17-3.15). CONCLUSIONS Women in jail and under community justice supervision reported a high prevalence of risk factors for cervical cancer. Because of their high prevalence of abnormal Pap testing, women in criminal justice settings may be appropriate targets for improved cervical cancer screening, prevention with human papillomavirus (HPV) vaccination, risk reduction education, and treatment.

The association between social stressors and drug use/hazardous drinking among former prison inmates

Social stressors are associated with relapse to substance use among people receiving addiction treatment and people with substance use risk behaviors. The relationship between social stressors and drug use/hazardous drinking in former prisoners has not been studied. We interviewed former prisoners at baseline, 1 to 3 weeks post prison release, and follow up, between 2 and 9 months following the baseline interview. Social stressors were characterized by unemployment, homelessness, unstable housing, problems with family, friends, and/or significant others, being single, or major symptoms of depression. Associations between baseline social stressors and follow-up drug use and hazardous drinking were analyzed using multivariable logistic regression. Problems with family, friends, and/or significant others were associated with reported drug use (AOR 3.01, 95% CI 1.18-7.67) and hazardous drinking (AOR 2.69, 95% CI 1.05-6.87) post release. Further research may determine whether interventions and policies targeting social stressors can reduce relapse among former inmates.

Gender and risk behaviors for HIV and sexually transmitted infections among recently released inmates: A prospective cohort study

Women in prison have a higher prevalence of HIV than men. After release from prison, former inmates have the opportunity to engage in risk behaviors for HIV and other sexually transmitted infections (STIs). We sought to assess change in risk behaviors over time and the association of gender with risk behavior in the postrelease period. In this prospective cohort study, we interviewed 200 former inmates (51 women) approximately two weeks (baseline) and three months (follow-up) after release and tested them for HIV infection at follow-up. We examined the association of gender with unprotected vaginal or anal sex in the last seven days using chi-square and Fishers exact tests and multivariable logistic regression. At baseline, 22% of men and 41% of women reported unprotected vaginal sex (p < 0.01) and 5% of men and 8% of women reported unprotected anal sex (p = 0.51). Being younger (OR for each decade increase 0.48, 95% CI = 0.29–0.80), being gay/lesbian or being bisexual (compared with being heterosexual, OR = 4.74, 95% CI = 1.01–22.17 and OR = 3.98, 95% CI = 1.41–11.26, respectively), or reporting a drug of choice of heroin/speedballs or cocaine/crack (compared with marijuana/no drug of choice, OR = 24.00, 95% CI = 5.15–111.81 and OR = 3.49, 95% CI = 1.20–10.18, respectively) was associated with unprotected vaginal or anal sex after adjusting for race, homelessness, and hazardous drinking. At follow-up, 21% of men and 44% of women reported unprotected sex (p = 0.005), and female gender (OR = 4.42, 95% CI = 1.79–10.94) and hazardous drinking (compared with not meeting criteria for hazardous drinking, OR = 3.64, 95% CI = 1.34–9.86) were associated with unprotected sex, adjusting for race and homelessness. In this population with a high prevalence of HIV, we demonstrated persistent engagement in sexual risk behavior during the postrelease period. Enhanced efforts to promote sexual health and reduced risk behavior among both male and female current and former prison inmates are needed, including improved access to preventive care and HIV and STI screening, testing, and treatment.

Attitudes Toward Naloxone Prescribing in Clinical Settings: A Qualitative Study of Patients Prescribed High Dose Opioids for Chronic Non-Cancer Pain

BackgroundOver the last 2 decades, medical providers have increasingly prescribed pharmaceutical opioids for chronic non-cancer pain, while opioid overdose death rates have quadrupled. Naloxone, an opioid antagonist, can be prescribed to patients with chronic pain to reverse an opioid overdose, yet little is known about how patients perceive this emerging practice.ObjectiveThis study assessed the knowledge and attitudes toward naloxone prescribing among non-cancer patients prescribed opioids in primary care.DesignQualitative study design using semi-structured interviews.ParticipantsAdults (N = 24) prescribed high-dose (≥100 morphine mg equivalent daily dose) chronic opioid therapy in eight primary care internal medicine, family medicine and HIV practices in three large Colorado health systems.ApproachInductive and deductive methods were used to analyze interview transcripts.Key ResultsThemes emerged related to knowledge of and benefits, barriers and facilitators to naloxone in primary care. Patients reported receiving limited education about opioid medication risks from providers and limited knowledge of naloxone. When provided with a description of naloxone, patients recognized its ability to reverse overdoses. In addition to pragmatic barriers, such as medication cost, barriers to naloxone acceptance included the perception that overdose risk stems from medication misuse and that providers might infer that they were misusing their opioid medication if they accepted a naloxone prescription, prompting an opioid taper.Facilitators to the acceptance of naloxone included medical providers’ using empowering, non-judgmental communication practices, framing naloxone for use in “worst case scenarios” and providing education and training about opioids and naloxone.ConclusionsWhile patients recognized the utility of naloxone prescribing, we identified important barriers to patient acceptance of naloxone prescribing. To improve the naloxone prescribing acceptability in primary care practice, medical providers and health systems may need to enhance patient education, employ empowering, non-judgmental communication styles and adequately frame discussions about naloxone to address patients’ fears.

A Patient Navigation Intervention for Drug-Involved Former Prison Inmates

BACKGROUND Former prison inmates experience high rates of hospitalizations and death during the transition from prison to the community, particularly from drug-related causes and early after release. The authors designed a randomized controlled trial (RCT) of patient navigation to reduce barriers to health care and hospitalizations for former prison inmates. METHODS Forty former prison inmates with a history of drug involvement were recruited and randomized within 15 days after prison release. Participants were randomized to receive 3 months of patient navigation (PN) with facilitated enrollment into an indigent care discount program (intervention) or facilitated enrollment into an indigent care discount program alone (control). Structured interviews were conducted at baseline, 3 months, and 6 months. Outcomes were measured as a change in self-reported barriers to care and as the rate of health service use per 100 person-days. RESULTS The mean number of reported barriers to care was reduced at 3 and 6 months in both groups. At 6 months, the rate of emergency department/urgent care visits per 100 person-days since baseline was 1.1 among intervention participants and 0.5 among control participants (P = .04), whereas the rate of hospitalizations per 100 person-days was 0.2 in intervention participants and 0.6 in control participants (P = .04). CONCLUSIONS Recruitment of former inmates into an RCT of patient navigation was highly feasible, but follow-up was limited by rearrests. Results suggest a significantly lower rate of hospitalizations among navigation participants, although the rate of emergency department/urgent care visits was not improved. Patient navigation is a promising, pragmatic intervention that may be effective at reducing high-cost health care utilization in former prison inmates.

Prediction Model for Two-Year Risk of Opioid Overdose Among Patients Prescribed Chronic Opioid Therapy

BackgroundNaloxone is a life-saving opioid antagonist. Chronic pain guidelines recommend that physicians co-prescribe naloxone to patients at high risk for opioid overdose. However, clinical tools to efficiently identify patients who could benefit from naloxone are lacking.ObjectiveTo develop and validate an overdose predictive model which could be used in primary care settings to assess the need for naloxone.DesignRetrospective cohort.SettingDerivation site was an integrated health system in Colorado; validation site was a safety-net health system in Colorado.ParticipantsWe developed a predictive model in a cohort of 42,828 patients taking chronic opioid therapy and externally validated the model in 10,708 patients.Main MeasuresPotential predictors and outcomes (nonfatal pharmaceutical and heroin overdoses) were extracted from electronic health records. Fatal overdose outcomes were identified from state vital records. To match the approximate shelf-life of naloxone, we used Cox proportional hazards regression to model the 2-year risk of overdose. Calibration and discrimination were assessed.Key ResultsA five-variable predictive model showed good calibration and discrimination (bootstrap-corrected c-statistic = 0.73, 95% confidence interval [CI] 0.69–0.78) in the derivation site, with sensitivity of 66.1% and specificity of 66.6%. In the validation site, the model showed good discrimination (c-statistic = 0.75, 95% CI 0.70–0.80) and less than ideal calibration, with sensitivity and specificity of 82.2% and 49.5%, respectively.ConclusionsAmong patients on chronic opioid therapy, the predictive model identified 66–82% of all subsequent opioid overdoses. This model is an efficient screening tool to identify patients who could benefit from naloxone to prevent overdose deaths. Population differences across the two sites limited calibration in the validation site.