PriSUD-Nordic-Diagnosing and Treating Substance Use Disorders in the Prison Population: Protocol for a Mixed Methods Study

Substance use disorders, severe mental illness and risk of reoffending among women released from prison: a national cohort study

Women with a clinical history of a severe mental illness (SMI) or multiple mental disorders involving substance use disorder (SUD) might be at increased risk of re-offending after release from prison. This retrospective cohort study merged data from the Norwegian prison release study (nPRIS) with other registry sources. All women released from a Norwegian prison between 2011-2019 were followed for two years after date of release. Adjusting for several known risk factors, we used logistic regression to estimate risk of violent (VR), drug-related (DR) or other reoffending (ORE) after release among women with a history of SUD and severe mental illness (SUD-SMI), SMI, SUD and other mental illness (SUD-OMI) or a history of multiple SUDs (POLY-SUD) in comparison to a reference population with no history of such disorders or combination of disorders. Relative to the reference population, after adjusting for other relevant risk factors, women with a history of SUD-SMI (ORVR 2.27, 95% CI 1.37-3.76; ORDR 2.10, 95% CI 1.49-2.95), SUD-OMI (ORVR 1.81, 95% CI 1.11-2.47; ORDR 1.53, 95% CI 1.11-2.10) or POLY-SUD (ORVR 1.87, 95% CI 1.04-3.31; ORDR 2.51, 95% CI 1.80-3.49) were at significantly greater risk of violent and drug-related reoffending. Women with a history of SMI were at significantly greater risk of other reoffending (ORORE 2.64, 95% CI 1.21-5.30). Women with a clinical history of a severe mental illness (SMI) or multiple mental disorders involving substance use disorder (SUD) have an elevated risk reoffending.

The burden of mental health and somatic disorders among people experiencing incarceration later in life: A 13-year cohort study

BACKGROUND

The growing number of older incarcerated individuals presents unique challenges for prison systems traditionally tailored for younger, healthier populations. Research on this demographic is crucial for informing effective health and correctional policies.

METHOD

Using data from the nPRIS-cohort, all people incarcerated at age 50 or older in Norway 2010-2022 were included. Study prevalence for selected disorders were calculated based on ICD-10 diagnoses registered in The Norwegian Patient Registry up until a person's last release date. One-year prevalence was calculated at prison entry each calendar year.

RESULTS

Including 1120 women and 9667 men; 63 % of women and 62 % of men aged 50-64, and 70 % of women and 75 % of men aged 65+ were diagnosed with a somatic disorder. Among women, 63 % (50-64 years) and 49 % (65+ years) had a mental health disorder, as did 53 % and 38 % of the men. There were significant differences in diagnostic prevalence between sex and age groups. Thirty-eight percent of the population had comorbid diagnoses, higher among the youngest women (50-64 year: 46 %). The one-year prevalence of individuals with mental disorders increased from 23 % in 2010 to 34 % in 2022, while the one-year prevalence of communicable and noncommunicable diseases remained consistent over time.

CONCLUSIONS

This study presents the first comprehensive description of the mental and somatic health burden of older individuals incarcerated in Norway. Our results underscore the urgent need for correctional and health services to implement tailored interventions that address the unique healthcare requirements of this aging population.

Estimated effects of opioid agonist treatment in prison on all-cause mortality and overdose mortality in people released from prison in Norway: a prospective analysis of data from the Norwegian Prison Release Study (nPRIS)

BACKGROUND

Overdose is the leading cause of death for people released from prison, and opioid agonist treatment is associated with reductions in mortality after imprisonment. However, few studies have explored the interplay of the potential modifiable risk factors and protective factors for mortality after release from prison. We aimed to describe all-cause mortality and overdose mortality among individuals released from Norwegian prisons during 2000-22 and to identify pre-existing risk factors associated with both types of mortality among these individuals for 6 months.

METHODS

For this prospective analysis, we used data from the Norwegian Prison Release Study (nPRIS), which includes all people in prison in Norway between Jan 1, 2000, and Dec 31, 2022; the Norwegian Cause of Death Registry; the Norwegian Prison Registry; the Norwegian Patient Registry; and Statistics Norway. All prisons in Norway that were open during this period were included. People who did not have a Norwegian personal identification number or were serving their sentence outside of prison units were excluded from this analysis. To identify pre-existing risk factors associated with all-cause and overdose mortality among people released from prison, we left-censored the observation period on Jan 1, 2010, creating a subsample of individuals. We calculated crude mortality rates (CMRs) and corresponding 95% CIs as the number of deaths per 100 000 person-years for several time periods after release. The primary outcomes were all-cause mortality and overdose mortality according to the ICD-10, assessed in all participants and analysed via two separate Cox proportional-hazards models.

FINDINGS

The total nPRIS cohort included 112 877 individuals released from prison in Norway between 2000 and 2022, 11 995 (10·6%) of whom were female and 100 865 (89·4%) of whom were male. We identified 13 004 instances of all-cause mortality and 3085 instances of overdose mortality during the 1 463 035 person-years. The estimated CMR for all-cause mortality was 889 (95% CI 874-904) per 100 000 person-years and for overdose mortality was 211 (203-218) per 100 000 person-years. Among people diagnosed with opioid use disorder before entering prison during 2010-22 (n=6830), provision of opioid agonist treatment was estimated to be associated with reductions in both all-cause mortality (hazard ratio 0·58, 95% CI 0·39-0·85) and overdose mortality (0·51, 0·31-0·82) in the 6 months after leaving prison after adjustment for sociodemographic, prison-related, and clinical characteristics.

INTERPRETATION

In people diagnosed with opioid use disorder released from Norwegian prisons, opioid agonist treatment provided while in prison was a protective factor for both all-cause and overdose mortality at 6 months. Provision of opioid agonist treatment while in prison is crucial in reducing mortality for 6 months after release and should be available to all people in prison who have treatment needs.

FUNDING

South-Eastern Norway Regional Health Authority and the Research Council of Norway.

The prevalence of substance use disorders among people in Norwegian, Danish and Swedish prisons: A multi-national cohort study, 2010-19

AIMS

We estimated the prevalence of substance use disorders (SUDs) in the Norwegian, Danish and Swedish prison populations and compared the prevalence of SUDs in the national prison populations with country-specific general population prevalence rates.

DESIGN

A multi-national cohort study using data from the National Prison Registries linked to the National Patient Registries in Norway, Denmark and Sweden.

SETTING AND PARTICIPANTS

We used data from the PriSUD-Nordic study, including national prison populations aged 19 years and older in Norway (2010-19), Denmark (2010-18) and Sweden (2010-13). A total of 119 507 Individuals (108 971 men and 10 536 women) contributing to 191 549 incarcerations were included in the study (Norway: 45432 men; 5429 women, Denmark: 42 162 men; 3370 women, Sweden: 21 377 men; 1737 women).

MEASUREMENT

We calculated a study prevalence and prevalence at entry to prison for all types of SUDs before imprisonment each consecutive year of observation in each prison population. We also extracted country-specific 1-year prevalence rates from the Global Burden of Diseases database to calculate comparative national prevalence ratios.

FINDINGS

The study prevalence of any SUD was approximately 40% [Norway: 44.0%, 95% confidence interval (CI) = 43.6-44.5%; Denmark: 39.9%, CI = 39.5-40.4%; Sweden: 39.1%, CI = 38.4-39.7%] in all three countries. Women had a significantly higher study prevalence of any SUD compared with men (Norway: 55.8 versus 42.6%, P < 0.001; Denmark 43.1 versus 39.7%, P = 0.004; Sweden: 51.7 versus 38.0%, P < 0.001). Prevalence estimates were higher for SUDs among people in prison than in the general population. We observed an increasing proportion of people with SUDs entering prison in Norway (P = 0.003), while the proportion was more stable in Denmark and Sweden.

CONCLUSIONS

Substance use disorders (SUDs) appear to be highly prevalent among the Scandinavian prison populations compared with the general population, especially among women. In Norway, there was a relative increase in SUDs from 2010 to 2019.

Evaluation of heroin-assisted treatment in Norway: protocol for a mixed methods study

BACKGROUND

Opioid agonist treatment (OAT) for patients with opioid use disorder (OUD) has a convincing evidence base, although variable retention rates suggest that it may not be beneficial for all. One of the options to include more patients is the introduction of heroin-assisted treatment (HAT), which involves the prescribing of pharmaceutical heroin in a clinical supervised setting. Clinical trials suggest that HAT positively affects illicit drug use, criminal behavior, quality of life, and health. The results are less clear for longer-term outcomes such as mortality, level of function and social integration. This protocol describes a longitudinal evaluation of the introduction of HAT into the OAT services in Norway over a 5-year period. The main aim of the project is to study the individual, organizational and societal effects of implementing HAT in the specialized healthcare services for OUD.

METHODS

The project adopts a multidisciplinary approach, where the primary cohort for analysis will consist of approximately 250 patients in Norway, observed during the period of 2022-2026. Cohorts for comparative analysis will include all HAT-patients in Denmark from 2010 to 2022 (N = 500) and all Norwegian patients in conventional OAT (N = 8300). Data comes from individual in-depth and semi-structured interviews, self-report questionnaires, clinical records, and national registries, collected at several time points throughout patients' courses of treatment. Qualitative analyses will use a flexible inductive thematic approach. Quantitative analyses will employ a wide array of methods including bi-variate parametric and non-parametric tests, and various forms of multivariate modeling.

DISCUSSION

The project's primary strength lies in its comprehensive and longitudinal approach. It has the potential to reveal new insights on whether pharmaceutical heroin should be an integral part of integrated conventional OAT services to individually tailor treatments for patients with OUD. This could affect considerations about drug treatment even beyond HAT-specific topics, where an expanded understanding of why some do not succeed with conventional OAT will strengthen the knowledge base for drug treatment in general. Results will be disseminated to the scientific community, clinicians, and policy makers.

TRIAL REGISTRATION

The study was approved by the Norwegian Regional Committee for Medical and Health Research Ethics (REK), ref.nr.:195733.

Mortality in women with a history of incarceration in Norway: a 20-year national cohort study

BACKGROUND

Women carry a substantial burden of psychiatric, somatic and lifestyle-related morbidity in the prison context. By describing causes of death and estimating the risk and burden of mortality compared with the general population, this study investigates how mortality operates in this highly marginalized and under-researched population.

METHODS

In this registry-based study of all women incarcerated in Norwegian prisons from 2000 to 2019 (N = 11 313), we calculated crude mortality rates, years of lost life and, by using mortality in age-matched women from the general population as a reference, age-standardized mortality ratios and years of lost life rates.

RESULTS

Over a mean follow-up time of 10.7 years, at a median age of 50 years, 9% of the population had died (n = 1005). Most deaths (80%) were premature deaths from an avoidable cause. Drug-induced causes and deaths from major non-communicable diseases (NCDs) were most frequent (both 32%). Compared with women in the general population, women with a history of incarceration were more likely to die from any cause. Trends in annual age-standardized years of lost life rates suggest that the mortality burden associated with major NCDs has gradually replaced drug-induced causes.

CONCLUSIONS

Women with a history of incarceration die at a greater rate than their peers and largely from avoidable causes. The profile of causes contributing to the substantial burden of mortality placed on this population has changed over time and has important implications for future efforts to reduce morbidity and the risk of premature death following release from prison.

The prevalence and comorbidity of mental health and substance use disorders in Scandinavian prisons 2010-2019: a multi-national register study

BACKGROUND

Mental health disorders are common among people in prison, but their prevalence in the Scandinavian prison population remain unclear. In this multinational register study, we examined the prevalence of mental health disorders and the comorbidity of substance use disorders (SUDs) with other mental health disorders in this population. Further, we investigated how the prevalence of mental disorders at prison entry had changed in Norway, Denmark, and Sweden over the study period.

METHODS

The three study cohorts included all individuals, aged 19 or older, whom had been imprisoned in Norway (2010-2019), Denmark (2011-2018), and Sweden (2010-2013). Mental disorders were defined as ICD-10 diagnoses (F-codes) registered in the national patient registers. The study prevalence was estimated based on recorded diagnoses during the entire study follow-up period in each respective country. The one-year prevalence of mental disorders was estimated for each calendar year for individuals entering prison during that year.

RESULTS

The Scandinavian prison cohorts included 119 507 individuals released 191 549 times during the study period. Across all three countries a high proportion of both women (61.3%-74.4%) and men (49.6%-57.9%) had at least one mental health disorder during the observation period. The most prevalent disorders were SUDs (39.1%-44.0%), depressive disorder (8.1%-17.5%), and stress related disorder (8.8%-17.1%). Women (31.8%-41.1%) had higher levels of mental health and substance use comorbidities compared to men (20.8%-27.6%). The one-year prevalence of any mental health disorder increased over time with a 33% relative increase in Norway, 8% in Denmark, and 10% in Sweden. The proportion of individuals entering prison with a comorbid SUD and other mental disorder had also increased.

CONCLUSIONS

While the incarceration rate has been decreasing during the past decade in the Scandinavian countries, an increasing proportion of people entering prison have a diagnosed mental health disorder. Our results suggest that prisons should provide adequate treatment and scale up services to accommodate the increasing proportion of people with complex health needs among incarcerated people.

Exploring mental health comorbidities and opioid agonist treatment coverage among people in prison: A national cohort study 2010-2019

INTRODUCTION

Despite a high prevalence of opioid use disorder (OUD) among people in prison, there is little knowledge of how many receive the recommended opioid agonist treatment (OAT) and what characterizes those who receive OAT and those who do not when it comes to mental health comorbidities. We aimed to describe people with OUD in Norwegian prisons over a ten-year period and their OAT status, and to investigate comorbidity of mental health disorders stratified by gender.

METHODS

Data from the PriSUD study, including all people (≥19 years old) imprisoned in Norway between 2010 and 2019, linked to national patient registry data, including ICD-10 codes. We calculated the prevalence (1-year and 10-year) of OUD and OAT, and mental health comorbidity stratified on OAT-status and gender.

RESULTS

Among the cohort (n=51,148), 7 282 (14.2%) were diagnosed with OUD during the period of observation. Of those, 4 689 (64.4%) received OAT. People with OUD had high levels of comorbidity, including other drug use disorders (92.4% OAT, 90.3% non-OAT), alcohol use disorder (32.1% OAT, 44.4% non-OAT) and any other mental health disorders (61.6% OAT, 68.2% non-OAT). The proportion receiving OAT among people with OUD increased markedly during the ten years of observation; from 35.7% in 2010-70.9% in 2019.

CONCLUSION

People with OUD, both receiving OAT and not, had substantially more mental health comorbidities than the non-OUD population. Understanding how the prison population changes over time especially in terms of mental health needs related to OUD, is important for correctional health service planning.

Psychiatric morbidity among women in Norwegian prisons, 2010-2019: a register-based study

PURPOSE

Research suggests that women in prison have more mental health problems than men and are prone to suffer from more severe psychiatric disorders. This study utilizes national registry data to describe demographic and psychiatric gender differences in Norwegian prisons, and to investigate comorbid psychiatric disorders and time trends in psychiatric morbidity among women.

METHODS

Longitudinal data from the Norwegian Prison Release Study linked with the Norwegian Patient Registry and data from Statistics Norway provided information on health care utilization, socioeconomic status, and history of psychiatric disorders among all individuals (nwomen = 5,429; nmen = 45,432) who were incarcerated in a Norwegian prison between 2010 and 2019.

RESULTS

Women were more likely than men to have a history of any psychiatric disorder (75% vs. 59%). Substance use disorders and dual disorders were highly prevalent in both genders, yet highest among women (56 and 38% respectively, versus 43 and 24% among men). From 2010 to 2019, we found a considerable increase in the 12-month prevalence of most diagnostic categories among women entering prison.

CONCLUSION

Psychiatric and dual disorders are highly prevalent in Norwegian prisons, and especially among women. The proportion of women entering prison with a recent history of mental health problems has increased rapidly over the last decade. Women's prison institutions need to adjust health and social services, and awareness about substance use and other psychiatric disorders in order to meet the increasing proportion of women facing these challenges.