In Oregon, people released from prison were 10 times more likely to overdose on opioids compared to the general population, according to a new study that tracked prison release and overdose data from 2014 to 2018. The risk of overdose doubled during the first two weeks of release, and formerly incarcerated women were almost twice as likely as men to experience an opioid overdose. A team of scientists from Oregon State University, Oregon Health & Science University and the Oregon Department of Corrections shared these findings which were published in the Journal of Substance Use and Addiction Treatment. The study looked at both fatal and non-fatal opioid overdoses using data collected from the Department of Corrections, state Medicaid insurance claims for emergency room and hospital admissions, as well as death certificates. Joining us are Dan Hartung, a professor in the College of Pharmacy at Oregon State University and Elizabeth Waddell, an associate professor at the OHSU-PSU School of Public Health, to talk about the research and new efforts in Oregon to expand access to substance use treatment both during and after incarceration.
This transcript was created by a computer and edited by a volunteer.
Dave Miller: This is Think Out Loud on OPB. I’m Dave Miller. Oregonians released from prison are 10 times more likely to overdose on opioids than the general population. That’s according to a new study that dug into data from 2014 to 2018. The first two weeks post release were the most dangerous time and formerly incarcerated women were almost twice as likely as men to experience an overdose. For more on this study and its implications. I’m joined by two of its authors. Dan Hartung is a professor in the College of Pharmacy at Oregon State University. Elizabeth Waddell is an associate professor in the OHSU PSU School of Public Health. Welcome to both of you.
Elizabeth Waddell: Thank you.
Dan Hartung: Thank you.
Miller: Elizabeth, first. Why are recently released people so much more likely to overdose?
Waddell: Yeah, that’s a great question. And there are a couple of big buckets of reasons. So the first one is releasing from prison is a really chaotic time. As you can imagine, folks are trying to reconnect with loved ones, support systems and community. They’re looking for employment, looking for permanent housing, just taking care of basic needs of food, clothing and shelter. So for those even who are seeking treatment for substance use disorders, it may not be the immediate priority and they may not know exactly where to go. And we can talk about that more later. The second bucket of reasons has to do with returning to the use of opioids after being abstinent for a longer period of time. And most folks who are in prison are going to be abstinent from opioids or are certainly using very rarely. So when they go out into community, if they try to use at the same amounts that they might have been using coming in, their bodies can’t handle it. And so the risk of overdosing just physically is much higher.
Miller: Dan Hartung. This, embedded in Elizabeth Wardell’s answer, could be the answer to this question. But I’m curious about the first two weeks post release because it seems that is a dangerous time, the most dangerous time. What’s special about those first two weeks?
Hartung: I think as Liz just pointed out, in those first two weeks, for individuals who are being released, this is a very stressful period in their release period. And they have been, for the most part, without opioid use and they may be put into communities where many of their friends are using substances and there just might be more exposure to those substances and especially in the environment where fentanyl around here is so common, and a very potent opioid. Just any small amount of exposure to that can put them into overdose pretty easily.
Miller: You didn’t just look into data about fatal overdoses. You also looked into non-fatal ones. And my understanding is that’s one of the novel aspects of this study, one of things that sets it apart from earlier studies. Why did you want to do that? What’s significant about non-fatal overdoses?
Hartung: Right. And so that’s a great point. There have been other studies that have looked at release from prison that have really only tracked opioid-related fatalities. And so we recognize that fatal overdoses only comprise about 10% of all opioid overdoses. And so we wanted to get a more comprehensive understanding of the overall burden of overdose after release in this population. And so we worked with the DOC, the Department of Corrections and several health agencies to combine a variety of different data sources to, again, get a more comprehensive assessment of both fatal and non- fatal events.
Miller: And Elizabeth Waddell, to call it non fatal doesn’t mean that they’re not serious, right, in terms of the potential health consequences?
Waddell: That’s right. It doesn’t mean they’re not serious at all. And in fact, all of the data that we used for our study, the non-fatal overdoses came from emergency department and hospital admissions. So these are the overdoses that were serious enough to show up in hospital.
Miller: Why is it that women who were recently released from prison were much more likely than their male counterparts to experience an overdose?
Waddell: So in our study, we found that women were more than 50% more likely than men releasing from prison to overdose.
Miller: Let alone the general population?
Waddell: Correct, 50% more likely than their male counterparts releasing from prison in Oregon. So we know a few things about female prison populations compared to male prison populations. First, it’s much more of a rare event for a woman to end up in prison. In Oregon, the entire prison population is about 13% women give or take. So those women also have a different risk profile than males. We see higher rates of documented substance use disorders, higher rates of mental health treatment needs and these are needs that are known and documented in the prison administrative data. So we see a high risk population of women with complex treatment needs. So bringing all of that risk to release is going to be associated with a higher risk of overdose.
Miller: What do all of your findings suggest about the level of addiction support services that were available to people both when they were in prison and right after they were released. And I should say again, we’re talking about this time period that the data covers from 2014 to 2018. So at that time, what was available to people when they were incarcerated and after they were just released?
Waddell: So I want to be careful about speaking about too much of the programmatic details where the researchers were not privy to all of the DOC programming information. But generally there’s more available now than there was then. In the past couple of years, there has been much more medication for opioid use disorder offered to adults in Oregon’s prison facilities than there was then.
Miller: I guess one of the things that I’m wondering [about], and this goes back to the answers to my first two questions, Don Hartung, maybe you can take your first attempt at answering. I’m just curious, what will it take for someone to leave prison and to either not want to start using again or to have their lives stable enough that even if they were maybe prone to substance use disorder, they would feel enough stability that they could handle the newness of the situation?
Hartung: This wasn’t directly addressed in our paper. Our paper, the project, was part of a larger study that looked at a pilot program that involved linking people who were released from prison, actually linking women, to what are called certified recovery mentors, to help them ease that transition into the community, help them find stable housing and more importantly, related to their substance use disorder, help them get connected with treatment facility in their community, for the communities that we were actually working with. So that project we’re working on is a pilot. But I think that there’s a lot of innovative things that are going on and not only in Oregon, but across the country that involve stepping up resources for individuals who are being released from prison that, at least in those projects, are showing really positive outcomes for those individuals.
Miller: Elizabeth Waddell, you were actually on Think Out Loud to talk about that pilot in 2019. So 4 or 5 years ago, if my math is correct. What do we know at this point about the effectiveness of that pilot program?
Waddell: The hard data documenting the effectiveness program is to come. But what I can tell you is that we offered this pilot program, which was to start a medication for opioid use disorder before their release, and there was a lot of acceptance of that treatment pre-release. And our participants had the opportunity to meet, in person, with support from the Department of Corrections in their facility, before release. Twice, sometimes three times. They could build up that trusted relationship with their mentor who very often met them at the gate on release day and helped provide a smooth transition to treatment right away.
Miller: Dan Hartung, we’ve talked about this a number of times over the years, that Oregon has among the worst rates of substance use disorder prevalence in the country and ranks among the worst for access to treatment. What does that mean in terms of this particularly vulnerable population? Because those numbers are statewide. But we’re talking about people who have just been released from prison and are now fully on their own or largely on their own?
Hartung: Right. There are definitely challenges in Oregon related to treatment access. We know that many of the treatments that are available, there’s several FDA approved medications, buprenorphine, methadone, naltrexone which is an opioid antagonist, that all three of these medications are very effective at improving outcomes for people with use disorders. And so I think, in particular for these individuals who are released from prison, as I mentioned earlier, there’s a number of projects ongoing across the country that are trying to step up their availability of these medications both in prison and also try to ease the transition as people are released to make sure that they are actually on treatment when they’re released from prison.
Miller: How much of that has to do with funding and for example, Medicaid?
Hartung: In Oregon, I think the DOC is proactive about trying to enroll people on Medicaid as they’re released. I know there’s discussion across the country about using Medicaid funds to fund some of that treatment in the prison.
Miller: California and Massachusetts may be working on that now?
Hartung: I don’t know all the details of what they’re doing and what is afoot in Oregon. But I know that that’s an active area of policy discussion and would definitely help because the studies that have looked at using these therapies in prison have shown really positive results and reducing overdose burden.
Miller: Elizabeth Waddell, you focused on this time period 2014-2018, which was really before the huge recent spike in fentanyl in Oregon and around the country. Do you have a sense for how fentanyl itself is affecting this particular population post release?
Waddell: We know how it’s affecting the general population. So even comparing Oregon to the rest of the country, in the last couple of years, our overdose rate in the general population has spiked about 40% compared to 16% or so nationwide. So there’s no reason to believe that the risk of overdose has declined. And as Dr. Hartung mentioned earlier, the fentanyl in the drug supply now really makes everyone who’s using an opioid at a higher risk for an overdose.
Miller: We’re talking about the population of people who were in state prisons, meaning at least a year behind bars, maybe much longer and then released. But there are county lockups where people could be there for a day or a week or six months or more and sort of cycle through much more rapidly. What does this study or all the research that you’ve done suggest about the risks, in terms of opioid overdoses for that population and possible interventions?
Waddell: I think that what all of this research points to is there’s a need for increased intervention around release planning and around connection to health care services, mental health service, physical health services, specifically substance use treatment providers at that exit. Jails have an even greater challenge of release planning because we don’t know necessarily how long adults will be incarcerated. So high rates of substance abuse, high rates of addiction, certainly for folks coming into jail is probably at the level, potentially higher. I don’t have that data in front of me, but the release planning is going to be much more difficult.
Miller: Dan Hartung, what are you most interested in studying next?
Hartung: Great question. So I think the one thing we haven’t mentioned yet today is that we are currently in the process of refreshing all of our data. This study goes through the end of 2018 and there’s been a lot that’s happened since the end of 2018, including the emergence of fentanyl in full force in Oregon, as well as what happened with the pandemic - really disrupting treatment and probably increasing the burden of drug use and overdoses in the state. So we hope to get a better sense of what’s going on on the ground with this refreshed data in the next probably six to eight months, hopefully.
Miller: Dan Hartung and Elizabeth Waddell, thanks very much. Elizabeth Waddell is an associate professor at the OHSU PSU School of Public Health. Dan Hartung is a professor in the College of Pharmacy at Oregon State University.
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