Release from Prison Equivalent to Death Sentence for Some

SEATTLE, Jan. 10 -- Persons newly released from prison, within their first two weeks of freedom, have a nearly 13-fold higher risk of death than those in the general population.

And even two years after release, former inmates have a 3.5-fold greater risk of dying than others in the community, found Ingrid A. Binswanger, M.D., of the University of Washington in Seattle, and colleagues in the Washington State Department of Corrections, and the University of Colorado in Denver.

The leading causes of death among ex-convicts were drug overdose, cardiovascular disease, murder and suicide, the investigators wrote in the Jan. 11 issue of the New England Journal of Medicine.

The findings suggest the need for planned reintegration of inmates through use of halfway houses, work-release programs, drug-treatment programs, drug abuse education, and preventive medical care to modify cardiac risk factors, the researchers wrote.

Dr. Binswanger and colleagues conducted a retrospective study of the fates of inmates released from Washington State prisons from July 1999 to December 2003. They linked prison records with the National Death Index, and compared data on the inmates to those from a CDC epidemiologic database containing information about the general population.

They compared death rates among the former inmates to those of other state residents with the use of indirect standardization.

They found that of the 30,237 inmates released during the study period, 443 died during a mean follow-up of 1.9 years. The overall mortality rate was 777 deaths per 100,000 person-years.

Adjusted for age, gender, and race, the risk of death among former inmates was 3.5 times higher than that of other state residents (95% confidence interval, 3.2 to 3.8).

"During the first two weeks after release, the risk of death among former inmates was 12.7 (95% CI, 9.2 to 17.4) times that among other state residents, with a markedly elevated relative risk of death from drug overdose (129; 95% CI, 89 to 186).

Women recently released from prison had an overall relative risk for death of 5.5 (95% CI, 4.2-7.3), compared with 3.3 for men (95% CI 3.0-3.7, P=0.002).

The leading cause of death among former inmates was drug overdose (103 deaths), representing nearly a quarter of all deaths, the authors wrote. "Of the 38 deaths occurring within two weeks after release, 27 were from overdoses. Within the first two weeks after release, the rate of death from overdose was 1,840 per 100,000 person-years (95% CI, 1213 to 2677). The adjusted relative risk of death from overdose was 129 (95% CI, 89 to 186) among released inmates within 2 weeks after release, as compared with other state residents."

Other causes of death and their relative risks included cardiovascular disease, 2.1 (95% CI, 1.6-2.7); homicide, 10.4 (95% CI, 8.0-13.6); suicide 3.4 (95% CI, 2.5-4.7); cancer, 1.67 (95% CI, 1.2-2.2); motor vehicle accident 3.4 (95% CI, 2.4-4.8); and liver disease 4.7 (95% CI, 3.2-7.2).

"Possible interventions after release include providing intensive case management during the period immediately following release and improving access to and continuity of medical and mental health care," the authors recommended. "In addition to possible reductions in mortality after release, there might be secondary benefits for society from such interventions, in the form of increased public safety.

Prison authorities can also help to protect the health of inmates while they're still behind bars by allowing the distribution of condoms, and by implementing needle-exchange programs, suggested Susan Okie, M.D., a contributing editor for the NEJM, in a perspective published in the same issue.

"Critics in the public health community have been urging U.S. prison officials to do more to prevent HIV transmission, to improve diagnosis and treatment in prisons, and to expand programs for reducing high-risk behavior after release," she wrote. "The debate over such preventive strategies as providing condoms and needles reflects philosophical differences, as well as uncertainty about the frequency of HIV transmission inside prisons."

Dr. Okie pointed to the model HIV-prevention program in place in the Rhode Island state prison, in Cranston.

"At the Rhode Island prison," she wrote, "the medical program focuses on identifying HIV-infected inmates, treating them, teaching them how to avoid transmitting the virus, addressing drug dependence, and when they're released, referring them to a program that arranges for HIV care and other assistance, including methadone maintenance treatment if needed. The prison offers routine HIV testing, and 90% of inmates accept it. One third of the state's HIV cases have been diagnosed at the prison."