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"In most countries, problematic drug use is dealt with primarily as a criminal justice issue, rather than a health issue. Accordingly, a large proportion of people in prison have a history of alcohol, tobacco and/or illicit drug use and, despite the best efforts of correctional authorities, some continue to use these substances in prison, often in very risky ways. After release from prison, many relapse to risky substance use, and are at high risk of poor health outcomes, preventable death, or reincarceration.In this edited volume, for the first time we bring together 40 contributors from 10 countries to review what is known about alcohol, tobacco and illicit drug use in people who cycle through prisons, and the harms associated with use of these substances. We consider some evidence-based responses to these harms - both in prison and after return to the community - and discuss their implications for policy reform.This book is international in scope and multi-disciplinary in character. It brings together and integrates the perspectives of public health and addictions researchers, criminologists and correctional leaders, epidemiologists, physicians, and human rights lawyers. Our contributors are unified in their commitment to evidence-informed policy - that is, doing what we know works. An overarching theme pervading all of the chapters is that people who cycle through prisons come from the community, and almost always return to the community. Their health problems are therefore our health problems; in other words, 'prisoner health is public health'"--Provided by publisher

This edited volume provides the first ever comprehensive, international and multi-disciplinary review of the evidence regarding substance use and harms in people who cycle through prisons and jails. Grounded in solid evidence and a human rights framework, the text provides a roadmap for evidence-based reform

IntroductionThe province of BC, Canada is in the grips of a sustained overdose epidemic. People released from prison are at increased risk of fatal drug overdose, but the impact of the overdose epidemic on mortality after release from prison in BC is poorly understood. Few studies have been able to examine risk factors for overdose death in this population.
Objectives and ApproachWe aimed to (a) measure risk of overdose-related and all-cause death in different time periods after release from prison; and (b) identify risk factors for overdose-related and all-cause death. In a random 20% sample of the population of BC, Canada, we identified those released from prison 2015-2017 and examined linked health and correctional records for this cohort.
ResultsOf 6106 persons released from prison 2015-2017, 77 (1.3%) died from any cause and 48 (0.8%) died from overdose 2015-2017. The incidence of all-cause death was 16.1 (95%CI 13.7-18.8) per 1000 person years, and the incidence of overdose death was 11.2 (95%CI 9.2-13.5) per 1000 person years. Risk factors for overdose death included a history of 3 or more incarcerations (HR=3.00, 95%CI 1.67-5.39), co-occurring substance use disorder and mental illness (HR=4.73, 95%CI 2.94-7.62), chronic physical morbidity (HR=3.10, 95%CI 1.97-4.88), and being dispensed benzodiazepines (HR=3.31, 95%CI 2.27-4.84) or opioids for pain (HR=6.77, 95%CI 3.86-11.89). The incidence of fatal overdose was significantly higher in the first two weeks post-release than at any other time during follow-up.
ConclusionPeople released from prison in BC are at markedly increased risk of preventable death, mainly due to overdose. As such, people transitioning from prison to the community should be a key target population for overdose prevention efforts. To be maximally effective, these efforts must go beyond provision of methadone and naloxone on release, to consider physical and mental health comorbidities, and psychosocial disadvantage.

IntroductionAdults released from incarceration experience complex physical and mental health problems, and are at markedly increased risk of preventable death. Despite this, not enough is known about the granular epidemiology of mortality in this population to inform development of targeted, evidence-based responses.
Objectives and ApproachWe created the Mortality After Release from Incarceration Consortium (MARIC), a multi-disciplinary collaboration from 12 countries representing 30 cohorts of adults with a history of incarceration. The combined sample size is 1,210,168, with 58,840 deaths recorded over 8,261,743 person-years of follow-up time. In this protocol paper, using a two-step, individual participant data meta-analysis (IPDM-A) methodology involving 22 MARIC cohorts, we calculated 1) a crude mortality rate (CMR; with 95% confidence intervals) for each individual cohort over the first 84 days (12 weeks) following release; and 2) a combined, meta-analysed CMR for the same period.
ResultsOf 1,704,208 individual releases, we observed 4,018 deaths over the first 84 days. The overall CMR over the first 84 days after release was 1610.97 deaths per 100,000 person-years (95% CI: 1263.4 - 1958.5). The rate was highest on the day of release (5768.0; 95% CI: 3296.5 - 8239.4), which was significantly higher than on days 4-84.
Conclusion/ImplicationsAdults released from incarceration were at an acutely increased risk of death on the day of release, and this risk remained elevated for at least the first 12 weeks. The MARIC study will provide decisive and empirical evidence to guide clinicians and policy makers in reducing mortality in this marginalized

IntroductionHigh rates of self-harm resulting in acute health service contact have been observed in adults released from prison. Contact with health services due to self-harm is a key intervention opportunity to prevent deleterious health outcomes. Little is known about subsequent mental health service contact after discharge from acute health services.
Objectives and ApproachWe aimed to describe mental health service contact after discharge from acute health service contacts following self-harm in a representative sample of adults released from prison. Ambulance, emergency department (ED), hospital inpatient and ambulatory mental health service records were probabilistically linked to pre-release interview data. Self-harm events after release were identified from ICD codes and coded from case notes in ambulance, ED, and hospital records. We calculated the time between discharge from ambulance, ED, or hospital after self-harm and subsequent contact with mental health services. Factors predicting the likelihood of mental health service contact were examined using multivariate logistic regression.
ResultsOf 1307 adults released from prison, 108 (8.3%) experienced 218 self-harm events resulting in acute health service use in the community. Of these presentations, 0%, 59%, and 50% of discharges from ambulance attendances, ED and hospital, respectively, had subsequent contact with a specialist mental health service within 7 days of that acute service contact. Mental health service contact within 7 days of acute service contact was positively associated with being female (adjusted odds ratio [AOR]: 3.27; 95%CI: 1.26-8.47) and being identified by prison staff as at risk for self-harm (AOR: 3.34; 95%CI: 1.29-8.62), and was negatively associated with dual diagnosis (AOR: 0.19: 95%CI: 0.06-0.61), substance use disorder only (AOR: 0.13; 95%CI: 0.04-0.48) and physical health functioning (AOR: 0.96; 95\%CI: 0.92-0.99).
Conclusion/ImplicationsAlmost half of adults with a recent history of incarceration discharged from acute health service after self-harm did not receive timely specialist mental health care. Improved integration of acute health services and ambulatory mental health services could improve outcomes for adults who present with self-harm.

The use of administrative health data for research, monitoring, and quality improvement has proliferated in recent decades, leading to improvements in health across many disease areas and across the life course. However, not all populations are equally visible in administrative health data, and those that are less visible may be excluded from the benefits of associated research.
Socially excluded populations -- including the homeless, people with substance dependence, people involved in sex work, migrants or asylum seekers, and people with a history of incarceration -- are typically characterised by health inequity. Yet people who experience social exclusion are often invisible within routinely collected administrative health data because information on their markers of social exclusion are not routinely recorded by healthcare providers. These circumstances make it difficult to understand the often complex health needs of socially excluded populations, evaluate and improve the quality of health services that they interact with, provide more accessible and appropriate health services, and develop effective and integrated responses to reduce health inequity.
In this commentary we discuss how linking data from multiple sectors with administrative health data, often called cross-sectoral data linkage, is a key method for systematically identifying socially excluded populations in administrative health data and addressing other issues related to data quality and representativeness. We discuss how cross-sectoral data linkage can improve the representation of socially excluded populations in research, monitoring, and quality improvement initiatives, which can in turn inform coordinated responses across multiple sectors of service delivery. Finally, we articulate key challenges and potential solutions for advancing the use of cross-sectoral data linkage to improve the health of socially excluded populations, using international examples.

ObjectivesPeople released from incarceration are at increased risk of death from diverse causes. We aimed to calculate the incidence of all-cause and cause-specific death after release from incarceration and identify individual-level risk factors for death.
ApproachWe conducted a series of individual participant data meta-analyses using data from >1.3 million adults released from incarceration in eight countries from 1980-2018. We used random effects meta-analysis to estimate the pooled all-cause and cause-specific crude mortality rates (CMRs), with 95% confidence intervals (CI) for the entire follow-up period, and for specific time periods after release from incarceration, overall and stratified by age, sex, and region.
ResultsWe included 1,395,318 people, 10,164,341 person-years of follow-up time, and 72,920 deaths in our analyses. The overall pooled CMR was 727 (95%CI: 623-840) per 100,000 person-years, with no difference between males and females. The risk of death was highest during the first week following release (all-cause CMR: 1,612, 95%CI: 1048-2,287, I2=91.5%), and the three most common causes of death across the entire follow-up period were 1) alcohol and other drug poisoning (CMR=144, 95%CI: 99-197); 2) cardiovascular disease (CMR: 102, 95%CI: 85-121); and 3) cancer and other neoplasms (CMR=74, 95%CI: 85-121). Leading causes of death varied across time periods following release from incarceration.
ConclusionOur findings indicate the need for routine monitoring of mortality following release from incarceration. The distribution of cause of death varies over time, such that clinical decision-making needs to be informed by the proximity to release from incarceration. The elevated risk of death in first 7 days following release highlights the urgent need for coordinated transitional care – including substance use and mental health treatment – and injury prevention initiatives.

Introduction: Mental health professionals working in acute inpatient mental health wards are involved in a complex interplay between an espoused commitment by government and organizational policy to be recovery-oriented and a persistent culture of risk management and tolerance of restrictive practices. This tension is overlain on their own professional drive to deliver person-centered care and the challenging environment of inpatient wards. Safewards is designed to reduce conflict and containment through the implementation of 10 interventions that serve to improve the relationship between staff and consumers. The aim of the current study was to understand the impact of Safewards from the perspectives of the staff. Methods: One hundred and three staff from 14 inpatient mental health wards completed a survey 12 months after the implementation of Safewards. Staff represented four service settings: adolescent, adult, and aged acute and secure extended care units. Results: Quantitative results from the survey indicate that staff believed there to be a reduction in physical and verbal aggression since the introduction of Safewards. Staff were more positive about being part of the ward and felt safer and more connected with consumers. Qualitative data highlight four key themes regarding the model and interventions: structured and relevant; conflict prevention and reducing restrictive practices; ward culture change; and promotes recovery principles. Discussion: This study found that from the perspective of staff, Safewards contributes to a reduction in conflict events and is an acceptable practice change intervention. Staff perspectives concur with those of consumers regarding an equalizing of staff consumer relationships and the promotion of more recovery-oriented care in acute inpatient mental health services.

IntroductionDespite an elevated prevalence of self-harm in the incarcerated adult population, little is known about patterns of self-harm following release from prison.
Objectives and ApproachBaseline self-report interviews with 1315 adults immediately prior to release from prison in Queensland, Australia, combined with interrogation of linked health data from >3750 post-release emergency department presentations, >2000 ambulance attendances, and corrections data during periods of re-incarceration.
ResultsApproximately 5% of all contacts with medical emergency services following release from prison resulted from self-harm. These were associated with being Indigenous, having a lifetime history of a mental disorder and having been identified by prison staff as being at risk of self-harm. Agreement between self-reported self-harm and medically-verified episodes of self-harm was poor.
Conclusion/ImplicationsEmergency services contacts resulting from self-harm following release from prison are common and represent an opportunity for tertiary intervention for self-harm. Our findings suggest that a self-reported history of self-harm should not be considered a reliable indicator of prior self-harm, or of future self-harm risk, in incarcerated adults.

IntroductionDrug-related death is substantially higher in formerly incarcerated adults compared to the general population. Despite this, remarkably little is known about the epidemiology of drug-related death among justice-involved adolescents. A richer understanding of drug-related mortality in justice-involved young people is essential for the development of effective, evidence-based interventions for this vulnerable group.
Objectives and ApproachIn a whole-population cohort of justice-involved young people in Queensland, Australia, we aimed to: 1) calculate the rate of drug-related death overall, and separately by intent and drug category; and 2) estimate the probability, and identify the predictors of, drug-related death. We probabilistically linked Youth Justice Queensland and National Death Index (NDI) records for every young person who came into contact with the youth justice system in Queensland between 1 January 1993 and 31 December 2014 (N=48,963). The NDI provided death data until 31 December 2017. Crude mortality rates (CMR) were calculatedoverall, separately by intent, and by prescribed versus illicit drug cause. Competing risk survival analysis will be conducted.
ResultsOf the 48,963 individuals, 1452 (3%) died by 31 December 2017. Of these, 204 (14%) deaths were due to drugs, yielding a CMR of 31 (95%CI:27-36) per 100,000 person-years. Most drug-related deaths were recorded as intentional (CMR=28; 95%CI:24-33 per 100,000 person-years) and deaths from prescribed medications were more common than illicit drugs (CMR=17; 95%CI:14-20 and CMR=11; 95%CI:9-14 per 100,000 person-years, respectively).
Conclusion / ImplicationsRates of drug-related deaths following contact with the youth justice system are disproportionately high and represent a major public health concern. Our findings highlight the importance of initiation of alcohol and other drug (AOD) treatment upon contact with the youth justice system and continuous engagement with community treatment after discharge from the youth justice system. Evidenced-base prevention strategies and efforts to improve the continuity of care are urgently needed.

IntroductionEpidemiologic studies have shown that people released from correctional facilities are at substantially increased risk of overdose-related death compared with the general population. However, the reported effect estimates are substantially heterogeneous, and the previous studies have important limitations in relative risk assessment for overdose-related death.
Objectives and ApproachBritish Columbia, Canada, has experienced an unprecedented epidemic of drug overdose, this study aimed to investigate how the overdose epidemic has affected formerly incarcerated persons. A 20% random sample of residents aged 18 years or older in British Columbia was used to conduct this cohort study. During the 5-year exposure period (January 2010 to December 2014), persons with an incarceration history were identified using provincial incarceration records. During the 3-year follow-up period (January 2015 to December 2017), overdose-related deaths were identified using linked administrative health data. Risk of overdose-related death was compared between persons who did and did not have an incarceration history using a Cox regression model.
ResultsOf 765,690 persons in the cohort, 5,743 had an incarceration history during the exposure period, and 634 died from drug overdose during the follow-up period. The mortality rate was 832 and 22 per 100,000 person-years for persons who did and did not have an incarceration history, respectively. Compared with persons without an incarceration history, and adjusting for individual and neighbourhood characteristics, persons who had an incarceration history were 3.67 times (95% confidence interval 2.93 - 4.59) more likely to die from drug overdose. This association was stronger for females, persons who did not have substance use disorder, and persons who were not dispensed opioids for pain or benzodiazepines.
Conclusion/ImplicationsPrevious incarceration is strongly associated with risk of overdose-related death. Specific interventions are needed to better prevent drug overdose for people released from incarceration.

IntroductionStudies of the health of prisoners have proliferated in the past decade. However, relatively few studies have examined health outcomes after release from custody. As such, although >30 million people are released from prison globally each year, the health and health service experiences of this population remain poorly understood.
Objectives and ApproachWell-powered longitudinal studies are essential for answering these questions but are expensive and difficult to conduct. Internationally, few such studies have been undertaken, and most suffer from either substantial and biased attrition, or recruitment bias. Cross-sectoral linkage of health and justice data circumvents some of these problems but presents its own ethical and methodological challenges. Large longitudinal studies, combining rich survey and clinical data with prospective data linkage, provide unique opportunities to examine and understand health outcomes for these highly marginalised individuals.
ResultsThis presentation will describe the process and challenges of establishing the world's largest (N=2,702) prospective study of adults released from prison: the Health After Release from Prison (HARP) cohort study. The cohort spans two Australian states and includes 538 women and 1,002 Indigenous Australians. An overview of the data collected through face-to-face surveys, medical record review, and prospective linkage with State-based health and correctional records, national Medicare and pharmaceutical records, and the National Death Index, will be provided. Some examples of how these data have been used to answer novel public health questions will be presented. The strengths and limitations of the cohort, and the applicability of this research design for other inclusion health populations, will be discussed.
Conclusion/ImplicationsGiven their extreme vulnerability, understanding the health of people who cycle through prisons is important to addressing health inequalities at the population level. Novel research designs that combine prospective data linkage with other data sources provide new opportunities to examine the health of socially excluded populations.

BACKGROUND: People who experience incarceration die by suicide at a higher rate than those who have no prior criminal justice system contact, but little is known about the effectiveness of interventions in other criminal justice settings. We aimed to synthesise evidence regarding the effectiveness of interventions to reduce suicide and suicide-related behaviours among people in contact with the criminal justice system. METHODS: We searched Embase, PsycINFO, MEDLINE, and grey literature databases for articles published between 1 January 2000 and 1 June 2021. The protocol was registered with PROSPERO (CRD42020185989). FINDINGS: Thirty-eight studies (36 primary research articles, two grey literature reports) met our inclusion criteria, 23 of which were conducted in adult custodial settings in high-income, Western countries. Four studies were randomised controlled trials. Two-thirds of studies (n=26, 68%) were assessed as medium quality, 11 (29%) were assessed as high quality, and one (3%) was assessed as low quality. Most had considerable methodological limitations and very few interventions had been rigorously evaluated; as such, drawing robust conclusions about the efficacy of interventions was difficult. INTERPRETATION: More high-quality evidence from criminal justice settings other than adult prisons, particularly from low- and middle-income countries, should be considered a priority for future research. FUNDING: This work was funded by the Australian government's National Suicide Prevention Taskforce. RB is supported by a National Health and Medical Research Council (NHMRC) Emerging Leader Investigator Grant (EL2; GNT2008073). MW is supported by a NHMRC Postgraduate Scholarship (GNT1151103). SF was funded by the NIHR HTA Programme (HTA Project:16/159/09).