Medication Assisted Treatments for Prisoners Reduce Risk of Death After Release?

Medication assisted Treatment (MAT) is an evidence-based treatment that can help prisoners reduce their use of illicit opioids and avoid risky health behaviors such as injection drug use.

Medications have been shown to be cost-effective for treating addiction in criminal justice populations (i.e., in health care, crime, and lost productivity), outweighing the costs associated with delivery of the service.

WHAT PROBLEM DOES THIS STUDY ADDRESS?

In 2002, the Scottish Prison Service introduced Medication assisted Treatment (MAT) to all prisons in Scotland for individuals who reported receiving methadone maintenance therapy prior to incarceration. By 2010, over half of prisoners with a history of injection drug use were receiving medications.

This study investigated whether the implementation of this program caused a decrease in drug-related deaths within the first 12 weeks after prison release with a focus on the first 2 weeks following release, a particularly vulnerable period where prisoners are most likely to resume drug use and experience accidental overdose.

HOW WAS THIS STUDY CONDUCTED?

The study included 150,517 prison releases from 131,472 Scottish prisoners occurring between January 1, 1996 and December 31, 2007. In order to be included in the study, a period of imprisonment prior to release had to be at least 2 weeks in length, chosen because this time frame was deemed sufficient for an individual to experience a loss of opioid tolerance.

For individuals with multiple periods of imprisonment, a prison release was only included in the study if it occurred at least 14 weeks after a prior release. This was to allow for 12 weeks of follow-up during which a drug-related death may have occurred and additional 2 weeks which was the minimum length of stay needed to be included in the study. Death records were obtained to determine if a drug-related death occurred in the 12 weeks after release.

The authors then compared drug-related deaths following prison release by age group and by periods before and after widespread OST implementation (1996-2002 and 2003-2007).

WHAT DID THIS STUDY FIND?

Drug-related deaths accounted for a larger percent of all deaths for the younger age group of 15-34 years (70%) than the older age group of 35+ years (32%).

The drug-related death rate in the 12 weeks following prison release decreased significantly from 3.8 deaths per 1000 releases prior to the Medication assisted Treatment (MAT) policy (1996-2002) to 2.2 deaths per 1000 releases after the implementation of the policy (2003-2007).

Percent of drug-related deaths out of total number of deaths occurring in the first 12 weeks by age group after release from prison.

When examining early drug deaths (i.e., within the first 2 weeks of release), this decline was not apparent. Prior to the Medication assisted Treatment (MAT) policy change, 57% of deaths from the 12 week period occurred in the first two weeks versus 56% after the policy change. This finding was similar when deaths were restricted to opioid-related deaths, though data was only available on specific drug-related deaths from 2000-2007.

The period following the change in Medication assisted Treatment (MAT) policy in Scottish prisons saw a decrease in drug-related deaths in the first 12 weeks after release from prison. However, this study did not show support for this policy in reducing the number of deaths occurring in the first 2 weeks after release.

This is contrary to other studies that point toward a short-term protective effect of Medication assisted Treatment (MAT) following release from prison (see here) where people on MAT in the 4 weeks after release experienced a 75% lower risk of death.

Since Medication assisted Treatment (MAT) alone may not help reduce deaths immediately after prison release, prisons may consider supplementing medications with outpatient psychosocial addiction treatments to aid in relapse prevention upon release.

WHY IS THIS STUDY IMPORTANT?

For prisoners with a history of injection heroin use, risk of overdose and drug-related death is increased following release from prison with the highest risk occurring in the first 2 weeks following release.

Risk is higher during this period because individuals who use heroin may experience a decrease in tolerance if they are abstinent while in prison. This can then result in an overdose if opioids are used at the same level as before incarceration.

Medication assisted Treatment (MAT) may be a solution to this problem, and the MAT program implemented in Scottish prisons presents an opportunity to study if this policy change has caused a decrease in drug-related deaths among recently released prisoners.

While there was a decrease in drug-related deaths after the implementation of the Medication assisted Treatment (MAT) policy, this result cannot be attributed to the policy change alone. As authors note, for example, country-wide trends in increased access to and safe prescribing of methadone could help explain this decrease. Moreover, there simply may be lower proportions of prisoners with opioid use disorder following this policy change.

Because studies show prisoners randomly assigned to OST have better outcomes than those who do not receive it (see here), this medication-assisted treatment should still be provided for prisoners, but it may not decrease the risk of drug-related death immediately following release from prison.

LIMITATIONS

It should be noted that this study was not designed to determine if Medication assisted Treatment (MAT) reduces drug-related deaths following release from prison, but rather to observe if there were changes in these rates following a policy that implemented widespread use of medications for addiction in all Scottish prisons.
Since data came from death registration in Scotland, there is a chance that deaths occurring outside of Scotland were not included.
Also, the death record data from 1996-1999 did not include information classifying deaths as opioid-related which may have impacted the estimates of changes in opioid-related death rates pre/post policy change.

NEXT STEPS

More research is needed to determine the best methods for addressing drug-related deaths immediately following release from prison.

BOTTOM LINE

For individuals & families seeking recovery: Medications may help reduce opioid use, but other addiction treatment services should be explored to help maintain recovery, especially upon release from prison.
For scientists: More research is needed to identify existing methods or design new interventions to reduce drug-related deaths immediately following release from prison.
For policy makers: This policy is important for allowing individuals who were on Medication assisted Treatment (MAT) prior to entering the criminal justice system to continue their treatment and provides an opportunity for other prisoners in need of MAT to access it. However, more work is needed to address high-risk drug use following release from prison.
For treatment professionals and treatment systems: If you have an opioid-using patient who is involved with the criminal justice system, a lower tolerance to the drug as a result of being abstinent from opioids in prison can lead to accidental overdose upon their release should they begin to use the drug again. Recommending or prescribing Medication assisted Treatment (MAT) and psychosocial treatment may prevent relapse and critical risks by creating a safer therapeutic bridge back into the community.