Opioid Agonist Treatment During Incarceration Saves Lives After Prison Release

Prison inmates with opioid use disorder (OUD) have a very high risk of death from overdose during the first 4 weeks post-release. This national prospective cohort study examined mortality rates among inmates with OUD released from 39 prisons in England; 8645 had received opioid agonist treatment (OAT; i.e., methadone or buprenorphine) while incarcerated and 6496 had not.

  • Of the 160 deaths in the year after release, 64% were drug-related poisonings (DRP).
  • During the first 4 weeks following release, OAT receipt reduced all-cause mortality (hazard ratio [HR], 0.25) and death from DRP (HR, 0.15). Adjustment for age, multiple risk, and community factors did not reduce these effects. However, this protective effect dissipated after 4 weeks.
  • The OAT group was twice as likely to enter community treatment as the untreated group, but no association was detected between community treatment and mortality.

Comments: This large study suggests that receiving OAT during incarceration attenuates the high risk of death in the month after release among inmates with OUD. Most of the benefit appears to come from reductions in drug-related poisonings, likely because OAT preserves opioid tolerance, which is protective against overdose. Although selection bias is a concern in this non-randomized study, OAT is often reserved for the most severe cases; hence, this investigation likely underestimates the true mortality benefit of OAT for this population. The forced detoxification of inmates with OUD is a cruel punishment unjustly served on top of their adjudicated sentence; this study admonishes us that it is frequently lethal to them as well.

Peter D. Friedmann, MD, MPH


Reference: Marsden J, Stillwell G, Jones H, et al. Does exposure to opioid substitution treatment in prison reduce the risk of death after release? A national prospective observational study in England. Addiction. 2017;112(8):1408–1418.

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