Background Being recently released from prison or discharged from hospital, or being dispensed opioids, benzodiazepines, or antipsychotics have been associated with an increased risk of fatal drug overdose. This study aimed to examine the association between these periods and non-fatal drug overdose using a within-person design.Methods In this self-controlled case series, we used data from the provincial health insurance client roster to identify a 20% random sample of residents (aged ≥10 years) in British Columbia, Canada between Jan 1, 2015, and Dec 31, 2017 (n=921 346). Individuals aged younger than 10 years as of Jan 1, 2015, or who did not have their sex recorded in the client roster were excluded. We used linked provincial health and correctional records to identify a cohort of individuals who had a non-fatal overdose resulting in medical care during this time period, and key exposures, including periods of incarceration, admission to hospital, emergency department care, and supply of medications for opioid use disorder (MOUD), opioids for pain (unrelated to MOUD), benzodiazepines, and antipsychotics. Using a self-controlled case series, we examined the association between the time periods during and after each of these exposures and the incidence of non-fatal overdose with case-only, conditional Poisson regression analysis. Sensitivity analyses included recurrent overdoses and pre-exposure risk periods. FindingsWe identified 4149 individuals who had a non-fatal overdose in 2015-17. Compared with unexposed periods (ie, all follow-up time that was not part of a designated risk period for each exposure), the incidence of non-fatal overdose was higher on the day of admission to prison (adjusted incidence rate ratio [aIRR] 2•76 [95% CI 1•51-5•04]), at 1-2 weeks (2•92 [2•37-3•61]), and 3-4 weeks (1•34 [1•01-1•78]) after release from prison, 1-2 weeks after discharge from hospital (1•35 [1•11-1•63]), when being dispensed opioids for pain (after ≥4 weeks) or benzodiazepines (entire use period), and from 3 weeks after discontinuing antipsychotics. The incidence of non-fatal overdose was reduced during use of MOUD (aIRRs ranging from 0•33 [0•26-0•42] to 0•41 [0•25-0•67]) and when in prison (0•12 [0•08-0•19]).Interpretation Expanding access to and increasing support for stable and long-term medication for the management of opioid use disorder, improving continuity of care when transitioning between service systems, and ensuring safe prescribing and medication monitoring processes for medications that reduce respiratory function (eg, benzodiazepines) could decrease the incidence of non-fatal overdose.

Objective: To investigate administration of pro re nata (PRN) medications and nurse-initiated medications (NIMs) in Australian aged care services over a 12-month period. Design: Twelve-month longitudinal audit of medication administrations. Setting and participants: Three hundred ninety-two residents of 10 aged care services in regional Victoria, Australia. Methods: Records of PRN and NIM administration were extracted from electronic and hard copy medication charts. Descriptive statistics were used to calculate medication administration per person-month. Poisson regression was used to estimate predictors of PRN administration. Results: Over a median follow-up of 12 months (interquartile range 10e12 months), 93% of residents were administered a PRN medication and 41% of residents an NIM on 21,147 and 552 occasions, respectively. The mean number of any PRN administration was 5.85 per person-month. The most frequently administered PRN medications per person-month were opioids 1.54, laxatives 0.96, benzodiazepines 0.72, antipsychotics 0.48, paracetamol 0.46, and topical preparations 0.42. Three-quarters of residents prescribed a PRN opioid or PRN benzodiazepine and two-thirds of residents prescribed a PRN antipsychotic had the medication administered on 1 or more occasions over the follow-up. Conclusions and Implications: Most residents were administered PRN medications. Administration was in line with Australian regulations and institutional protocols. However, the high frequency of PRN analgesic, laxative, and psychotropic medication administration highlights the need for regular clinical review to ensure ongoing safe and appropriate use.Ó 2020 AMDA e The Society for Post-Acute and Long-Term Care Medicine.Medication management is an increasingly complex and important component of quality care in residential aged care services (RACS). 1 Australian RACS are synonymous with long-term care facilities and nursing homes in other countries and provide permanent and respite accommodation for people who require access to 24-hour care that can no longer be provided in their own homes. 1 A review of the international literature suggests that up to 74% of residents take 9 or more regular medications, 2 with most residents dependent on staff for medication administration. Up to 94% of residents are prescribed pro re nata (PRN) or "as-needed" medications. 3 PRN medications are prescribed by the resident's physician and administered by nurses, or in some situations by care workers, on an as-needed basis. 4 Previous Australian and German research suggests residents are prescribed up to 4 PRN medications, 5e7 with analgesics and laxatives most frequently administered. 3 In addition to administering PRN medications, Australian guidelines permit registered nurses to initiate specific over-the-counter BA and LMC are employed by health services overseen by the Department of Health and Human Services.

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ObjectiveTo explore variation in medication regimen complexity in residential aged care facilities (RACFs) according to resident age, length of stay, comorbidity, dementia severity, frailty, and dependence in activities of daily living (ADLs), and compare number of daily administration times and Medication Regimen Complexity Index (MRCI) as measures of regimen complexity.MethodsThis study was a cross-sectional analysis of baseline data from the SImplification of Medications Prescribed to Long-tErm care Residents (SIMPLER) cluster-randomized controlled trial. The SIMPLER study recruited 242 residents with at least one medication charted for regular administration from 8 RACFs in South Australia. Comorbidity was assessed using the Charlson Comorbidity Index (CCI). Dementia severity was assessed using the Dementia Severity Rating Scale. Frailty was assessed using the FRAIL-NH scale. Dependence in ADLs was assessed using the Katz ADL scale.ResultsThe median age of participants was 87 years (interquartile range 81–92). Over one-third of participants (n=86, 36%) had 5 or more daily medication administration times. The number of daily administration times and MRCI scores were positively correlated with resident length of stay (rs=0.19; 0.27), FRAIL-NH score (rs=0.23; 0.34) and dependence in ADLs (rs=−0.21; −0.33) (all p<0.01). MRCI was weakly negatively correlated with CCI score (rs=−0.16; p=0.013). Neither number of daily administration times nor MRCI score were correlated with age or dementia severity. In multivariate analysis, frailty was associated with number of daily administration times (OR: 1.13, 95% CI: 1.03–1.24) and MRCI score (OR: 1.26, 95% CI: 1.13–1.41). Dementia severity was inversely associated with both multiple medication administration times (OR: 0.97, 95% CI: 0.94–0.99) and high MRCI score (OR: 0.95, 95% CI: 0.92–0.98).ConclusionResidents with longer lengths of stay, more dependent in ADLs and most frail had the most complex medication regimens and, therefore, may benefit from targeted strategies to reduce medication regimen complexity.

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IntroductionMore 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.   ObjectivesTo comprehensively document the incidence, timing, causes and risk factors for mortality in adults released from prison. MethodsWe 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. ResultsThe combined sample includes 1,337,993 individuals (89% male), with 75,795 deaths recorded over 9,191,393 person-years of follow-up. ConclusionsThe 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. Key wordsMortality; incarceration; prison; release; individual participant data meta-analysis; consortium; cohort.  

Aims To estimate the treated prevalence of mental illness, substance use disorder (SUD) and dual diagnosis and the association between dual diagnosis and fatal and non‐fatal overdose among residents of British Columbia (BC), Canada. Design A retrospective cohort study using linked health, income assistance, corrections and death records. Setting British Columbia (BC), Canada. Participants A total of 921 346 BC residents (455 549 males and 465 797 females) aged 10 years and older. Measurements Hospital and primary‐care administrative data were used to identify a history of mental illness only, SUD only, dual diagnosis or no history of SUD or mental illness (2010–14) and overdoses resulting in medical care (2015–17). We calculated crude incidence rates of non‐fatal and fatal overdose by dual diagnosis history. Andersen–Gill and competing risks regression were used to examine the association between dual diagnosis and non‐fatal and fatal overdose, respectively, adjusting for age, sex, comorbidities, incarceration history, social assistance, history of prescription opioid and benzodiazepine dispensing and region of residence. Findings Of the 921 346 people in the cohort, 176 780 (19.2%), 6147 (0.7%) and 15 269 (1.7%) had a history of mental illness only, SUD only and dual diagnosis, respectively; 4696 (0.5%) people experienced 688 fatal and 6938 non‐fatal overdoses. In multivariable analyses, mental illness only, SUD only and dual diagnosis were associated with increased rate of non‐fatal [hazard ratio (HR) = 1.8, 95% confidence interval (CI) = 1.6–2.1; HR = 9.0, 95% CI = 7.0–11.5, HR = 8.7, 95% CI = 6.9–10.9, respectively] and fatal overdose (HR = 1.6, 95% CI = 1.3–2.0, HR = 4.3, 95% CI = 2.8–6.5, HR = 4.1, 95% CI = 2.8–6.0, respectively) compared with no history. Conclusions In a large sample of residents of British Columbia (Canada), approximately one in five people had sought care for a substance use disorder or mental illness in the past 5 years. The rate of overdose was elevated in people with a mental illness alone, higher again in people with a substance use disorder alone and highest in people with a dual diagnosis. The adjusted hazard rates were similar for people with substance use disorder only and people with a dual diagnosis.

Purpose People released from incarceration are at increased risk of suicide compared to the general population. We aimed to synthesise evidence on the incidence of and sex differences in suicide, suicidal ideation, and self-harm after release from incarceration. Methods We searched MEDLINE, EMBASE, PsycINFO, Web of Science and PubMed between 1 January 1970 and 14 October 2021 for suicide, suicidal ideation, and self-harm after release from incarceration (PROSPERO registration: CRD42020208885). We calculated pooled crude mortality rates (CMRs) and standardised mortality ratios (SMRs) for suicide, overall and by sex, using random-effects models. We calculated a pooled incidence rate ratio (IRR) comparing rates of suicide by sex. Results Twenty-nine studies were included. The pooled suicide CMR per 100,000 person years was 114.5 (95%CI 97.0, 132.0, I2 = 99.2%) for non-sex stratified samples, 139.5 (95% CI 91.3, 187.8, I2 = 88.6%) for women, and 121.8 (95% CI 82.4, 161.2, I2 = 99.1%) for men. The suicide SMR was 7.4 (95% CI 5.4, 9.4, I2 = 98.3%) for non-sex stratified samples, 14.9 for women (95% CI 6.7, 23.1, I2 = 88.3%), and 4.6 for men (95% CI 1.3, 7.8, I2 = 98.8%). The pooled suicide IRR comparing women to men was 1.1 (95% CI 0.9, 1.4, I2 = 82.2%). No studies reporting self-harm or suicidal ideation after incarceration reported sex differences. Conclusion People released from incarceration are greater than seven times more likely to die by suicide than the general population. The rate of suicide is higher after release than during incarceration, with the elevation in suicide risk (compared with the general population) three times higher for women than for men. Greater effort to prevent suicide after incarceration, particularly among women, is urgently needed.