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Prison Release a Dangerous Health Time for Many

Former inmates have higher immediate risk of death from drug overdose, homicide and suicide, study finds

WEDNESDAY, Jan. 10, 2007 (HealthDay News) -- Former prison inmates face a much higher risk of death in the period right after their release, particularly from drug overdoses, a new study found.

The risk is highest -- 12.7 times that of the general population -- during the first two weeks after release. Overall, the excess risk is 3.5 times that of the general population, and the risk for both women and men doesn't return to normal levels until several weeks after release.

"I was expecting an increased risk of death, but I was surprised at the extent of the increase and by how there is such a strong vulnerable time in the first two weeks," said the study's lead author, Dr. Ingrid Binswanger, an assistant professor of medicine at the University of Colorado at Denver and Health Sciences Center. "It suggests that there might be things we can do to help people transition back."

The United States now has more people incarcerated than at any time in its history. At the end of 2005, more than 2 million people were being held in federal or state prisons or local jails, an increase of 2.7 percent from the end of 2004. On average, the number of prisoners has grown 3.3 percent annually since 1995, according to the U.S. Department of Justice.

Studies conducted in Europe and Australia have suggested that after-release mortality rates were higher in certain populations of inmates, including people with a history of intravenous drug use. But little information had been available for the United States.

"To the extent that I know, this is the first study of its kind in the United States," Binswanger said.

For her research, which is published in the Jan. 11 issue of the New England Journal of Medicine, Binswanger and colleagues looked at all inmates released from the Washington state Department of Corrections from July 1999 through December 2003. The prison records were then cross-referenced with the National Death Index, and resulting mortality rates were compared with Washington state residents matched for age, gender and race.

During that time frame, 30,237 inmates were released; 443 died during a follow-up period of almost two years. The leading causes of death were drug overdoses, cardiovascular disease, homicide and suicide.

"We found a number of causes of death that were in excess of what would be expected in a similar population in terms of age, race and gender," Binswanger said.

Drug overdoses -- especially from cocaine -- were particularly pronounced during the first two weeks, as were, to a lesser extent, homicide and suicide. Deaths from cardiovascular disease, along with cancer -- particularly lung cancer -- were also high but weren't concentrated as strongly in the first two weeks.

"Some of the findings make sense from a physiologic perspective," Binswanger said. "If you have an addiction and you've been relatively abstinent during the time you were incarcerated, then you return to a high level of drug use, you're more likely to have an overdose."

"The results point to the fact that drug-treatment programs are perhaps one of the most potentially beneficial kinds of interventions," she added.

The findings sounded a bell for two female inmates in New Mexico.

"We fool ourselves into thinking we're going to do [drugs] one last time before we go straight," said Anita C., currently being held at the Bernalillo County Metropolitan Detention Center (BCMDC) in Albuquerque. "Because we've been clean so long, we underestimate our tolerance."

Beth, another inmate at BCMDC, added, "We build our own reality in here and it's not what we expected when we get out. When we get out, our plans don't go how we wanted. We either start using [drugs] or end it all together."

A second article in the journal noted that just being in prison added to the risk of contracting a potentially fatal illness, such as HIV or tuberculosis.

In an accompanying perspective article, contributing editor Dr. Susan Okie pointed out that risky sexual activities are rife in U.S. prisons. Because sex is prohibited, condoms are not passed out (except on a limited basis in Vermont and Mississippi). One Rhode Island state prisoner said inmates use latex gloves, sandwich bags or nothing at all to protect themselves.

In the United States in 2004, according to the article, 1.8 percent of prison inmates were HIV-positive, more than four times the estimated rate in the general population. And while the risk of transmission while incarcerated is low, it's "not negligible," Okie said.

"Mr. M.", a middle-aged, HIV-positive inmate interviewed for the perspective piece at a medium-security compound in Rhode Island, said, "I've seen it all. We have a lot of risky [sexual] activities... Almost every second or minute, somebody's sneaking and doing something."

More information

For more on HIV transmission among male inmates, visit the U.S. Centers for Disease Control and Prevention.

SOURCES: Ingrid A. Binswanger M.D., assistant professor of medicine, University of Colorado at Denver and Health Sciences Center; Anita C. and Beth, inmates, Bernalillo County Metropolitan Detention Center, Albuquerque, N.M.; Jan. 11, 2006, New England Journal of Medicine; U.S. Department of Justice
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