The European Region of the World Health Organization (WHO) recently issued a report, Prevention of acute drug-related mortality in prison populations during the immediate post-release period.  
 
Many released prisoners die in the weeks after leaving jail. Reasons, says the WHO report, include decreased tolerance to drugs after a period of relative abstinence and the concurrent use of many drugs, each additional drug nearly doubling the risk of death from opioids. Other important factors are the lack of pre-release counselling, post-release follow-up and a failure to identify those at risk.
 
At the national level, WHO called for monitoring, risk assessment and evaluation of interventions, in particular: a standardized monitoring protocol to determine baseline mortality rates in the post-release period.
 
Straight Statistics has already drawn attention to frequently-posed parliamentary questions, dustily answered, on England’s failure to have a system for monitoring ex-prisoners’ drug-related deaths within the first fortnight post-release.
 
We have also blown the whistle on one of the reasons why England is so lacking  - because not even the fact/date of deaths which are subject to coroner’s inquiry need be registered until completion of the coroner’s inquiry which can take many months.
 
Knowing even the fact/date of deaths in the 2 weeks post-release would help enormously because most such deaths are drug-related. Indeed, even in the first12 weeks post-release, 60 per cent of ex-prisoner deaths were drug-related as shown by Merrall et al. (1) in a meta-analysis across six studies of drug-related deaths soon after release from prison.
 
The studies - from UK, USA and Australia - contributed over 69,000 person-years and 1,033 deaths in the first 12 weeks after release, 612 of which were drug-related. Three to 8-fold increased risk of drug-related death was found when comparing weeks 1+2 with weeks 3-12, but with notable heterogeneity between countries: UK 7.5 (95% CI: 5.7-9.9); Australia 4.0 (95% CI: 3.4-4.8); Washington State, USA 8.4 (95% CI: 5.0-14.2) and New Mexico State, USA 3.1 (95% CI: 1.3-7.1). Comparing weeks 3+4 with weeks 5-12, the pooled relative risk was 1.7 (95% CI: 1.3-2.2) so that the risk remained elevated up to at least the fourth week post-release.
 
In Scotland, there is both timely registration of the fact/date of death and look-back at every drug-related death to establish the deceased’s recent prison history: date of last reception into prison, date of last liberation, and from which prison. In addition, it should be possible to establish whether the deceased had received methadone during his/her last incarceration.
 
To be compliant with WHO’s recommendations, England needs first to sort out its registration of deaths and then either flag for mortality within 12 weeks of release all ex-prisoners or, like Scotland, conduct look-back into the prison antecedents of all drug-related deaths as a matter of public health routine (not as research).
 
Conflict of interest: SMB is co-author with Merrall et al. and is co-grantholder for a randomized prevention trial to reduce drug-related deaths soon after release.
 
 
References
1. Merrall ELC, Kariminia A, Binswanger IA, Hobbs MS, Farrell M, Marsden J, Hutchinson SJ, Bird SM. Meta-analysis of drug-related deaths soon after release from prison. Addiction 2010; 105: 1545-1554.