Factors associated with ongoing criminal engagement while in opioid maintenance treatment

Introduction: This study examines factors associated with criminal engagement among patients in opioid maintenance treatment (OMT). Methods: Questionnaire data recorded annually among 5 654 patients in the Norwegian OMT programme between 2005 and 2010 from seven regional treatment centres were available for analyses. Each patient answered approximately 4 times (mean: 4.11, SD: 1.46) generating a total of 18 538 questionnaires. The outcome variable of the study, engagement in criminal activity, was defined as whether a patient had been arrested, put in custody, been charged and/or convicted of a crime within the last 12 months prior to the completion of the questionnaire. Three types of covariates were included: demographical, psychosocial and drug use-related. Missing data were imputed using Multivariate Imputation by Chained Equations and regression parameters were estimated by Generalized Estimation Equations to account for correlated measurements. Results: Having a full-time job (aOR: 0.47, CI: 0.34-0.64) or being a student/having a part-time job (aOR: 0.72, CI: 0.59-0.88) was negatively associated with ongoing criminal involvement, as did having a stable living situation (aOR: 0.70, CI: 0.57-0.87). On the other hand, being male (aOR: 1.83, CI: 1.59-2.10), younger (aOR: 0.96, CI: 0.95-0.97) and using illicit drugs regularly (aOR: 3.00, CI: 2.56-3.52) was positively associated with ongoing criminal activity while in OMT. Conclusions: Stable accommodation and participation in meaningful daily activity was found to be protective in terms of ongoing criminal engagement. Focus on these modifiable, psychosocial factors should therefore be an important and integral aspect of opioid maintenance treatment.acceptedVersio

Large variations in all-cause and overdose mortality among >13,000 patients in and out of opioid maintenance treatment in different settings: a comparative registry linkage study

BackgroundOpioid maintenance treatment (OMT) has the potential to reduce mortality rates substantially. We aimed to compare all-cause and overdose mortality among OMT patients while in or out of OMT in two different countries with different approaches to OMT.MethodsTwo nation-wide, registry-based cohorts were linked by using similar analytical strategies. These included 3,637 male and 1,580 female patients enrolled in OMT in Czechia (years 2000–2019), and 6,387 male and 2,078 female patients enrolled in OMT in Denmark (years 2007–2018). The direct standardization method using the European (EU-27 plus EFTA 2011–2030) Standard was employed to calculate age-standardized rate to weight for age. All-cause and overdose crude mortality rates (CMR) as number of deaths per 1,000 person years (PY) in and out of OMT were calculated for all patients. CMRs were stratified by sex and OMT medication modality (methadone, buprenorphine, and buprenorphine with naloxone).ResultsAge-standardized rate for OMT patients in Czechia and Denmark was 9.7/1,000 PY and 29.8/1,000 PY, respectively. In Czechia, the all-cause CMR was 4.3/1,000 PY in treatment and 10.8/1,000 PY out of treatment. The overdose CMR was 0.5/1,000 PY in treatment and 1.2/1,000 PY out of treatment. In Denmark, the all-cause CMR was 26.6/1,000 PY in treatment and 28.2/1,000 PY out of treatment and the overdose CMR was 7.3/1,000 PY in treatment and 7.0/1,000 PY out of treatment.ConclusionCountry-specific differences in mortality while in and out of OMT in Czechia and Denmark may be partly explained by different patient characteristics and treatment systems in the two countries. The findings contribute to the public health debate about OMT management and may be of interest to practitioners, policy and decision makers when balancing the safety and accessibility of OMT

The mortality after release from incarceration consortium (MARIC): Protocol for a multi-national, individual participant data meta-analysis

Introduction More than 30 million adults are released from incarceration globally each year. Many experience complex physical and mental health problems, and are at markedly increased risk of preventable mortality. Despite this, evidence regarding the global epidemiology of mortality following release from incarceration is insufficient to inform the development of targeted, evidence-based responses. Many previous studies have suffered from inadequate power and poor precision, and even large studies have limited capacity to disaggregate data by specific causes of death, sub-populations or time since release to answer questions of clinical and public health relevance. Objectives To comprehensively document the incidence, timing, causes and risk factors for mortality in adults released from prison. Methods We created the Mortality After Release from Incarceration Consortium (MARIC), a multi-disciplinary collaboration representing 29 cohorts of adults who have experienced incarceration from 11 countries. Findings across cohorts will be analysed using a two-step, individual participant data meta-analysis methodology. Results The combined sample includes 1,337,993 individuals (89% male), with 75,795 deaths recorded over 9,191,393 person-years of follow-up. Conclusions The consortium represents an important advancement in the field, bringing international attention to this problem. It will provide internationally relevant evidence to guide policymakers and clinicians in reducing preventable deaths in this marginalized population

Harm to Others from Substance Use and Abuse: The Underused Potential in Nationwide Registers

This article considers the potential in using nationwide registers to study harm to others from substance use and abuse. The advantages of using registry data include the opportunity to include the data on the entire population nationwide and continuously updated longitudinal datasets; they allow for studying small subpopulations and have little missing data. Personal identification numbers and family numbers enable linkage of data from different registers. Such datasets can include extensive information on individual and family levels. In this article, we provide an introduction to nationwide registers and explain how they can be applied to investigate two types of third-party harms: harm to children and harm to partners/spouses from substance use and abuse in parents and partners/spouses. Finally, we discuss challenges, benefits, and ethical considerations regarding the use of such data

Criminal convictions among patients in opioid maintenance treatment in Norway. : A national cohort study

The reduction of criminal activity is an important aspect of drug treatment. Opioid maintenance treatment (OMT) is one of the most widespread treatment approaches for opioid dependence, and over the past decades researchers have generally agreed that OMT reduces criminal activity. Several factors may affect treatment outcome. Patients retained in long-term and continuous treatment experience less involvement in criminal activity during OMT, while patients who drop out of OMT tent to relapse into higher levels of drug use and criminal activity. There is also research supporting a link between patient outcome and the manner in which treatment programme services are delivered. In Norway, criminal activity among patients in OMT and associations with long-term treatment has previously not been sufficiently studied. On this background, this thesis focuses on the investigation of criminal convictions among a national cohort of OMT patients. Study aims The specific aims of this thesis were to investigate criminal convictions among patients before, during, and after OMT and to explore how the long-term retention patterns were associated with criminal convictions. Furthermore, to investigate criminal convictions among patients in four different treatment regions in Norway, and to estimate the time-continuous probability of criminal activity during OMT transition periods. Materials and methods In this study, the Norwegian OMT patient register was cross-linked with the Norwegian crime register. The OMT patient register comprised information on all patients who applied for (n=3789) and subsequently started (n=3221) OMT in Norway between 1997 and 2003. The Norwegian crime register comprised detailed information on all crime cases, and included the date of the criminal event and the indentified offender. Data from the national OMT register and the crime register were linked using a unique identification number assigned by the Norwegian state of all residents. The study included all registered criminal convictions for the cohort before, during, and after treatment. Results During the three years prior to OMT application, the cohort had more than 24 000 convictions. Almost 80% of all convictions were for acquisitive crimes and drug offences. Differences were found among those applying for treatment; almost 40% had no criminal convictions whereas 10% of the sample was responsible for about 40% of all convictions in total. During treatment the overall rates of criminal convictions were reduced to less than half of pre-treatment levels. Patients retained in continuous and long-term treatment had the lowest rates of criminal convictions during OMT, whereas patients who left treatment had relatively high levels of convictions during treatment regardless of whether they returned to treatment or not. Patients who dropped out of treatment had high levels of criminal convictions during the periods out of OMT. In the Central-Northern region more than 80% of patients were in continuous treatment compared to about 60% in the Eastern region. Regional differences were found in criminal convictions among patients in continuous treatment; compared to patients in the Eastern region, patients in the Southern and the Central-Northern region had respectively 44% and 81% less criminal convictions during treatment, and patients in the Western region had 60% more convictions. During the years prior to onset of treatment, the probability of a criminal event in the cohort was relatively stable, at approximately 0.4% daily. About three months before initiation of OMT criminal activity started to decrease before stabilizing at the onset of OMT at a new, significantly lower level of approximately 0.2% per day. During the weeks before dropping out of treatment, criminal activity increased, up until the final day of treatment. After treatment, the higher levels of criminal activity were stable and high. The patterns during periods of transition were the same across gender, age and pre-treatment convictions levels. Discussion and conclusion During treatment the overall rates of criminal convictions were reduced to less than half of pre-treatment levels. Patients who left OMT relapsed to more criminal convictions when out of treatment, and this elevated probability of criminal convictions could be identified during a critical period in the months prior to drop out. The increased levels of criminal convictions may serve as a visible marker of other forms of risk behaviour, and it is essential that clinical staff offer support to OMT patients who are at particular risk of dropping out of treatment. Awareness of the process by which the programmes are delivered is essential for improving treatment effectiveness. Treatment centres known to provide OMT with a particular focus on psychosocial rehabilitation were found to have most improvement in terms of reduction in crime during treatment. Rapid expansion of the national OMT programme without accompanying sufficient resources to maintain high standards of treatment might represent a challenge in term of optimal treatment delivery

Accounting for individual differences and timing of events: estimating the effect of treatment on criminal convictions in heroin users

Background The reduction of crime is an important outcome of opioid maintenance treatment (OMT). Criminal intensity and treatment regimes vary among OMT patients, but this is rarely adjusted for in statistical analyses, which tend to focus on cohort incidence rates and rate ratios. The purpose of this work was to estimate the relationship between treatment and criminal convictions among OMT patients, adjusting for individual covariate information and timing of events, fitting time-to-event regression models of increasing complexity. Methods National criminal records were cross linked with treatment data on 3221 patients starting OMT in Norway 1997–2003. In addition to calculating cohort incidence rates, criminal convictions was modelled as a recurrent event dependent variable, and treatment a time-dependent covariate, in Cox proportional hazards, Aalen’s additive hazards, and semi-parametric additive hazards regression models. Both fixed and dynamic covariates were included. Results During OMT, the number of days with criminal convictions for the cohort as a whole was 61% lower than when not in treatment. OMT was associated with reduced number of days with criminal convictions in all time-to-event regression models, but the hazard ratio (95% CI) was strongly attenuated when adjusting for covariates; from 0.40 (0.35, 0.45) in a univariate model to 0.79 (0.72, 0.87) in a fully adjusted model. The hazard was lower for females and decreasing with older age, while increasing with high numbers of criminal convictions prior to application to OMT (all p < 0.001). The strongest predictors were level of criminal activity prior to entering into OMT, and having a recent criminal conviction (both p < 0.001). The effect of several predictors was significantly time-varying with their effects diminishing over time. Conclusions Analyzing complex observational data regarding to fixed factors only overlooks important temporal information, and naïve cohort level incidence rates might result in biased estimates of the effect of interventions. Applying time-to-event regression models, properly adjusting for individual covariate information and timing of various events, allows for more precise and reliable effect estimates, as well as painting a more nuanced picture that can aid health care professionals and policy makers

For mye eller for lite medisiner? En nasjonal studie av forskrevne psykofarmaka blant innsatte i norske fengsler

SAMMENDRAGBakgrunn: Legemiddelbruk i den norske befolkningen er økende. Kunnskap om omfang, hvem brukerne er og bruksmønster er en forutsetning for optimalisering av legemiddelbruk i alle grupper av befolkningen. Samtidig finnes det ingen oppdaterte studier som viser bruk av forskrevne legemidler blant innsatte i Norge. Hensikten med denne studien er derfor å beskrive bruk av forskrevne psykofarmaka blant innsatte i fengsel før og under soning, samt undersøke hvilke faktorer som er assosiert med legemiddelbruk.Material og metode: Datamaterialet er fra «The Norwegian Offender Mental Health and Addiction Study», NorMA-studien, som ble gjennomført i perioden 2013-2014 ved 57 fengselsenheter i Norge. Totalt svarte 1495 innsatte (96 kvinner) på spørreskjema. Vi undersøkte selvrapportert bruk av psykofarmaka knyttet til sovemedisin,beroligendelegemidler,antidepressiva,LAR-legemidler,smertestillendelegemidlerogADHD-legemidler.Vibruktelogistiskeregresjonerforåundersøkesammenhenger mellom ulike bakgrunnsfaktorer og bruk av ulike legemidler under soning.Resultater: Sovemedisin varmest brukt, både før og under soning. Tjue prosent av innsatte brukte sove-medisin daglig under soning. Innsatte brukte mer psykofarmaka enn den generelle befolkningen, med unntak av smertestillende legemidler. Under soning var bruk av de fleste undersøkte psykofarmaka assosiert med betydelige psykiske plager, skadelig rusbruk, å motta økonomiske sosiale ytelser samt å ha hatt en oppvekst preget av rus og psykiske problemer.Konklusjon:Våre funn viser at innsattes psykiske helse og russituasjon bør ha høyprioritet under soning. Det er forventet at innsatte bruker mer forskrevne psykofarmaka enn den generelle befolkningen. At den generelle befolkningen bruker mer smertestillende enn innsatte, bør derfor undersøkes nærmere

Suicide in prison and after release: a 17-year national cohort study

Abstract Background People in prison have an extremely high risk of suicide. The aim of this paper is to describe all suicides in the Norwegian prison population from 2000 to 2016, during and following imprisonment; to investigate the timing of suicides; and to investigate the associations between risk of suicide and types of crime. Methods We used data from the Norwegian Prison Release study (nPRIS) including complete national register data from the Norwegian Prison Register and the Norwegian Cause of Death Register in the period 1.1.2000 to 31.12.2016, consisting of 96,856 individuals. All suicides were classified according to ICD-10 codes X60-X84. We calculated crude mortality rates (CMRs) per 100,000 person-years and used a Cox Proportional-Hazards regression model to investigate factors associated with suicide during imprisonment and after release reported as hazard ratios (HRs). Results Suicide accounted for about 10% of all deaths in the Norwegian prison population and was the leading cause of death in prison (53% of in deaths in prison). The CMR per 100,000 person years for in-prison suicides was 133.8 (CI 100.5–167.1) and was ten times higher (CMR = 1535.0, CI 397.9–2672.2) on day one of incarceration. Suicides after release (overall CMR = 82.8, CI 100.5–167.1) also peaked on day one after release (CMR = 665.7, CI 0–1419.1). Suicide in prison was strongly associated with convictions of homicide (HR 18.2, CI 6.5–50.8) and high-security prison level (HR 15.4, CI 3.6–65.0). Suicide after release was associated with convictions of homicide (HR 3.1, CI 1.7–5.5). Conclusion There is a high risk of suicide during the immediate first period of incarceration and after release. Convictions for severe violent crime, especially homicide, are associated with increased suicide risk, both in prison and after release