Does exposure to opioid substitution treatment in prison reduce the risk of death after release? A national prospective observational study in England
Does exposure to opioid substitution treatment in prison reduce the risk of death after release? A national prospective observational study in England
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DOI：
10.1111/add.13779
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发表时间：
2017-08-01
期刊：
影响因子：
6
通讯作者：
Hickman, Matthew
中科院分区：
文献类型：
--
作者：
Marsden, John;Stillwell, Garry;Hickman, Matthew
背景和目的监狱中的阿片类药物使用障碍（OUD）患者在释放后面临严重的死亡风险。我们估计监狱阿片类药物替代治疗（OST）是否能降低这种风险。设计前瞻性观察性队列研究，使用监狱卫生保健，国家社区药物滥用治疗和死亡登记。设置在英格兰39所成人监狱招募（32名男性; 7名女性）占研究计划期间英格兰OST治疗的95%。（招募时间：2010年9月-2013年8月;首次发布时间：2010年9月;最后一次发布时间：2014年10月; 2016年2月的随访;风险集中n=15141）。干预和比较在发布时，参与者被分类为暴露于OST（n=8645）或未暴露于OST（n=6496）。OST未暴露组未接受OST，或已退出，或有一个低dose.MeasurementsPrimary结局：全因死亡率（ACM）在前4周。次要结局：前4周内药物相关中毒（DRP）死亡; 4周至1年后ACM和DRP死亡;前4周内社区药物滥用治疗入院。未校正和校正的考克斯回归模型（协变量：性别、年龄、药物注射、问题酒精使用、苯二氮卓类药物的使用、可卡因、监狱转移和社区治疗的接纳），测试死亡率和社区治疗摄取的差异。OST暴露组6例，OST未暴露组18例[死亡率为0.93/100人-年（py）vs 3.67/100 py;风险比（HR）=0.25; 95%置信区间（CI）=0.10-0.64]。有18例DRP死亡：OST暴露组死亡率为0.47/100 py，而OST未暴露组为3.06/100 py（HR=0.15; 95% CI=0.04-0.53）。第一个月后死亡风险没有组间差异。OST暴露组更有可能在释放后第一个月进入药物滥用治疗（比值比2.47，95% CI=2.31-2.65）。OST对ACM和DRP死亡风险的保护作用不受人口统计学、过量风险因素、监狱转移或社区治疗的削弱（完全校正HR=0.25; 95% CI=0.09-0.64和HR=0.15; 95%CI =0.04-0.52）。结论在一项英国国家研究中，在释放后的第一个月内，基于监狱的阿片类药物替代疗法与全因死亡率降低75%和致命药物相关中毒降低85%相关。
Background and AimsPeople with opioid use disorder (OUD) in prison face an acute risk of death after release. We estimated whether prison-based opioid substitution treatment (OST) reduces this risk.DesignProspective observational cohort study using prison health care, national community drug misuse treatment and deaths registers.SettingRecruitment at 39 adult prisons in England (32 male; seven female) accounting for 95% of OST treatment in England during study planning.ParticipantsAdult prisoners diagnosed with OUD (recruited: September 2010-August 2013; first release: September 2010; last release: October 2014; follow-up to February 2016; n=15141 in the risk set).Intervention and ComparatorAt release, participants were classified as OST exposed (n=8645) or OST unexposed (n=6496). The OST unexposed group did not receive OST, or had been withdrawn, or had a low dose.MeasurementsPrimary outcome: all-cause mortality (ACM) in the first 4weeks. Secondary outcomes: drug-related poisoning (DRP) deaths in the first 4weeks; ACM and DRP mortality after 4weeks to 1year; admission to community drug misuse treatment in the first 4weeks. Unadjusted and adjusted Cox regression models (covariates: sex, age, drug injecting, problem alcohol use, use of benzodiazepines, cocaine, prison transfer and admission to community treatment), tested difference in mortality rates and community treatment uptake.FindingsDuring the first 4weeks after prison release there were 24 ACM deaths: six in the OST exposed group and 18 in the OST unexposed group [mortality rate 0.93 per 100 person-years (py) versus 3.67 per 100 py; hazard ratio (HR)=0.25; 95% confidence interval (CI)=0.10-0.64]. There were 18 DRP deaths: OST exposed group mortality rate 0.47 per 100 py versus 3.06 per 100 py in the OST unexposed group (HR=0.15; 95% CI=0.04-0.53). There was no group difference in mortality risk after the first month. The OST exposed group was more likely to enter drug misuse treatment in the first month post-release (odds ratio 2.47, 95% CI=2.31-2.65). The OST mortality protective effect on ACM and DRP mortality risk was not attenuated by demographic, overdose risk factors, prison transfer or community treatment (fully adjusted HR=0.25; 95% CI=0.09-0.64 and HR=0.15; 95% CI=0.04-0.52, respectively).ConclusionsIn an English national study, prison-based opioid substitution therapy was associated with a 75% reduction in all-cause mortality and an 85% reduction in fatal drug-related poisoning in the first month after release.