Alcohol and drug misuse are responsible for around a third of all deaths in former male prisoners and half in female ex-prisoners, a new study of almost 48000 ex-prisoners published in The Lancet Psychiatry journal has found. Moreover, the research shows that a substantial proportion of these deaths are from preventable causes, including accidents and suicide (42% in men and 70% in women).
Several studies have reported high death rates after release from prison, but few have looked at potential risk factors for these high rates. Led by Seena Fazel, Professor of Forensic Psychiatry at the University of Oxford, the study examined deaths in all individuals (47326 prisoners) released from prison in Sweden between January 1, 2000 and December 31, 2009. The causes of death were assessed and compared with imprisoned siblings without substance use disorder (both alcohol and illicit drug use) and other psychiatric disorders, to isolate the impact of the illnesses from the prison setting. The researchers then estimated the proportion of deaths that could be attributed to alcohol and substance abuse and other psychiatric disorders (eg, schizophrenia, ADHD, depression)—by calculating the population attributable fractions (PAF), the proportion of deaths that can be attributed to each risk factor.
Roughly 6% (2874) of prisoners died after release, during an average follow-up of 5 years. 1276 deaths (44%) were due to potentially preventable external causes, accounting for roughly 3% of all external cause mortality in Sweden between 2000 and 2009.
The researchers found a particularly high risk of death for prisoners with a history of drug and alcohol misuse following release from prison that persisted for years afterwards rather than just weeks as previously thought.
Around a third (34%) of all deaths in men and half (50%) in women released from prison were related to alcohol and substance use, even after accounting for the influence of socio-demographic, criminological, and familial (genetic and environmental) factors. Alcohol and substance abuse accounted for 42% of deaths from external causes in male ex-prisoners and 70% in female ex-prisoners. In contrast to previous research, the investigators found no evidence that other psychiatric disorders increased the post-release death rate.
The authors point out that although Sweden has a relatively low incarceration rate, the prevalence of substance abuse and severe psychiatric disorders reported in this study are similar to the UK, USA, and other high-income countries.
According to Professor Fazel, “Our striking findings show the potential for preventive and therapeutic programmes to significantly reduce the number of deaths from alcohol and substance misuse, which are highly prevalent among the 30 million people worldwide who spend time in prison every year. In England and Wales, we estimate that around 3% of all deaths from external causes can be prevented if alcohol and substance use disorders were fully treated in released prisoners. In the USA, where there are much higher incarceration rates, about 9% of deaths from external causes are potentially preventable.” 
He adds, “Although alcohol abuse is as common as drug abuse, and the high mortality risks following release are similar, it does not receive the same level of attention or funding. For example, in 2010–11 nearly half the prisons in England and Wales had no alcohol-related services available.” 
Writing in a linked Comment, Sarah Wakeman from Harvard Medical School, Boston, USA and Josiah Rich from Brown University, Providence, USA say, “Addiction is a treatable disease and decades of scientific evidence support the efficacy of treatment to improve clinical outcomes, save lives, and reduce societal costs…The withholding of evidence-based treatment for prisoners is arguably unethical and certainly unwise. In the USA, correctional facilities are mandated by the Supreme Court to provide medical care that meets the community standard. And yet, within state prisons people with drug use disorders largely go without care: of these people, only 0·8% receive detoxification services, 0·3% receive maintenance pharmacotherapy, 6·5% receive counselling by a professional, and 9·5% receive treatment in a residential facility…The absence of care in this deeply affected population translates into high costs to society and the communities that these individuals return to. As the Article shows, these costs also translate into avoidable deaths from a treatable illness.”
This study was funded by The Wellcome Trust, the Swedish Research Council, and the Swedish Research Council for Health, Working Life and Welfare.
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