TORONTO - Inmates of Ontario correctional facilities are 12 times more likely than the general public to die of a drug overdose within the first year following their release from incarceration, say researchers, who believe concrete interventions are needed to reduce these preventable deaths.
In a study published Wednesday in the journal PLOS ONE, researchers found that 702 of the almost 7,000 Ontarians who overdosed on drugs between 2006 and 2013 had been released from custody in a provincial jail or remand centre.
"The highest risk period is shortly after their release, in the days and the weeks following their release," said principal researcher Dr. Nav Persaud, a physician in the department of family and community medicine at St. Michael's Hospital in Toronto.
Nine per cent of these men and women died within the first two days of leaving custody and 20 per cent within the first week, the researchers found. Three-quarters of them were under age 45.
Although more men than women died due to an overdose, women had a much higher risk of death from drug toxicity compared to the general population: 27 times greater versus 10 times for men.
Persaud said 77 per cent of the deaths involved the use of one or more opioids, a powerful class of painkillers that includes oxycodone, fentanyl and morphine.
"The possible explanation for that is a loss of tolerance," he said. "It could be the case that the person before being incarcerated was using a substance at a certain dose, then during incarceration they either stopped using this substance or they were using it at a lower dose.
"And then after they are released they might return to their previous level of use, which because of a loss of tolerance, that medication can cause death."
In more than half of the cases involving opioid toxicity, the researchers determined from coroner and police reports that the victim had been with another person "who in principle could have intervened," he said.
One intervention would be injecting the person with the medication naloxone, which acts as an antidote to reverse the effects of opioid toxicity. Naloxone does not work for other types of drugs.
Up until early this week, those released from provincial custody apparently had no access to naloxone kits, which are available to substance abusers through public health units and community-based organizations through the Ontario Harm Reduction Distribution Program.
But following news reports about a bureaucratic tussle between the ministries of health and corrections that had prevented the distribution of naloxone to departing inmates, Health Minister Eric Hoskins announced Monday that the naloxone program would immediately be ramped up to include those newly released from provincial jails and remand centres.
"It's good that the Ministry of Health is taking action on this important issue and I support the distribution of naloxone kits to people being released from incarceration," said Persaud, adding that the change in policy needs to be evaluated over time to make sure the measure is effective in preventing deaths.
A similar program in Scotland, for instance, has had mixed results, he said.
Dr. Fiona Kouyoumdjian, a public health physician at St. Michael's Hospital and McMaster University, said the results of this study are in line with a recent study she also co-authored, which found that an inmate's risk of dying from an overdose was 56 times the national average in the first two weeks after release.
By one year, the risk was about 14 times higher, she said of the 2000 study, which looked at death rates among 50,000 inmates.
"It shows things haven't improved significantly, the death rates are still extremely high in the period after people are released from provincial facilities," said Kouyoumdjian, who also works as a part-time physician at the Hamilton-Wentworth Detention Centre.
While making naloxone available to inmates leaving custody is a significant step forward, she also believes the period of incarceration offers opportunities for improving a person's health and dealing with the social factors that can contribute to the risk of death from a drug overdose after they leave.
"We see people coming into jail who have a lot of challenges at the time of release. They need to reunite with family, sometimes repair situations that have happened with the family. They need to try to get their job back. They need to get their social services restarted. They have to find housing," she said Wednesday from Hamilton.
"All of these things are significantly stressful for people. And if someone has a pre-existing substance-use disorder, even if they were planning to not use or use less when they leave, being in what many would perceive as a crisis situation may well lead to them using either more or in more risky ways than people would usually choose to use."
Amber Kellen, director of community initiatives, research and policy at the John Howard Society of Toronto, said the study is "very important" because it shows how vulnerable people who have been incarcerated can be after they gain their freedom.
"(These are) things that as Ontarians we need to be aware of," she said, noting that John Howard staff are trained in overdose prevention and talk to soon-to-be-released inmates who identify as substance users about the need to be mindful about the dosage they take, to ensure they get their drugs from a trusted source, and not to use alone.
"People who go to jail are fathers, brothers, uncles, sisters and mothers," said Kellen, "and I think people are in increasingly precarious situations upon release."