Background Among former prisoners, a high rate of death has been documented in the early postrelease period, particularly from drug-related causes. Little is known about risk factors and trends in postrelease mortality in the past decade, especially given general population increases in overdose deaths from pharmaceutical opioids. Objective To determine postrelease mortality between 1999 and 2009; cause-specific mortality rates; and whether sex, calendar year, and custody factors were risk factors for all-cause, overdose, and opioid-related deaths. Design Cohort study. Setting Prison system of the Washington State Department of Corrections. Participants 76 208 persons released from prison. Measurements Identities were linked probabilistically to the National Death Index to identify deaths and causes of death, and mortality rates were calculated. Cox proportional hazards regression estimated the effect of age, sex, race or ethnicity, whether the incarceration resulted from a violation of terms of the person’s community supervision, length of incarceration, release type, and calendar year on the hazard ratio (HR) for death. Results The all-cause mortality rate was 737 per 100 000 person-years (95% CI, 708 to 766) (n = 2462 deaths). Opioids were involved in 14.8% of all deaths. Overdose was the leading cause of death (167 per 100 000 person-years [CI, 153 to 181]), and overdose deaths in former prisoners accounted for 8.3% of the overdose deaths among persons aged 15 to 84 years in Washington from 2000 to 2009. Women were at increased risk for overdose (HR, 1.38 [CI, 1.12 to 1.69]) and opioid-related deaths (HR, 1.39 [CI, 1.09 to 1.79]). Limitation The study was done in only 1 state. Conclusion Innovation is needed to reduce the risk for overdose among former prisoners. Primary Funding Source National Institute on Drug Abuse and the Robert Wood Johnson Foundation.

Background As physicians have increased opioid prescribing, overdose deaths from pharmaceutical opioids have substantially increased in the United States. Naloxone hydrochloride (naloxone), an opioid antagonist, is the standard of care for treatment of opioid induced respiratory depression. Since 1996, community-based programs have offered overdose prevention education and distributed naloxone for bystander administration to people who use opioids, particularly heroin. There is growing interest in translating overdose education and naloxone distribution (OEND) into conventional medical settings for patients who are prescribed pharmaceutical opioids. For this review, we summarized and classified existing publications on overdose education and naloxone distribution to identify evidence of effectiveness and opportunities for translation into conventional medical settings. Methods For this review, we searched English language PubMed for articles on naloxone based on primary data collection from humans, including feasibility studies, program evaluations, surveys, qualitative studies and studies comparing the effectiveness of different routes of naloxone administration. We also included cost-effectiveness studies. Results We identified 41 articles that represented 5 categories: evaluations of OEND programs, effects of OEND programs on experiences and attitudes of participants, willingness of medical providers to prescribe naloxone, comparisons of different routes of naloxone administration, and the cost-effectiveness of naloxone. Conclusions Existing research suggests that people who are at risk for overdose and other bystanders are willing and able to be trained to prevent overdoses and administer naloxone. Counseling patients about the risks of opioid overdose and prescribing naloxone is an emerging clinical practice which may reduce fatalities from overdose while enhancing the safe prescribing of opioids.

BACKGROUND:The rate of fatal unintentional pharmaceutical opioid poisonings has increased substantially since the late 1990s. Naloxone is an effective opioid antidote that can be prescribed to patients for bystander use in the event of an overdose. Primary care clinics represent settings in which large populations of patients prescribed opioids could be reached for overdose education and naloxone prescription. OBJECTIVE: Our aim was to investigate the knowledge, attitudes and beliefs about overdose education and naloxone prescription among clinical staff in primary care. DESIGN: This was a qualitative study using focus groups to elucidate both clinic-level and provider-level barriers and facilitators. SETTING: Ten primary care internal medicine, family medicine and infectious disease/HIV practices in three large Colorado health systems. METHODS: A focus group guide was developed based on behavioral theory. Focus group transcripts were coded for manifest and latent meaning, and analyzed for themes using a recursive approach that included inductive and deductive analysis. RESULTS: Themes emerged in four content areas related to overdose education and naloxone prescription: knowledge, barriers, benefits and facilitators. Clinical staff (N= 56) demonstrated substantial knowledge gaps about naloxone and its use in outpatient settings. They expressed uncertainty about who to prescribe naloxone to, and identified a range of logistical barriers to its use in practice. Staff also described fears about offending patients and concerns about increased risk behaviors in patients prescribed naloxone. When considering naloxone, some providers reflected critically and with discomfort on their own opioid prescribing. These barriers were balanced by beliefs that prescribing naloxone could prevent death and result in safer opioid use behaviors. LIMITATIONS: Findings from these qualitative focus groups may not be generalizable to other settings. CONCLUSION: In addition to evidence gaps, logistical and attitudinal barriers will need to be addressed to enhance uptake of overdose education and naloxone prescription for patients prescribed opioids for pain.

OBJECTIVE : There is inadequate evidence of long-term benefit and growing evidence of the risks of chronic opioid therapy (COT). Opioid dose reduction, or opioid tapering, may reduce these risks but may also worsen pain and quality of life. Our objective was to explore patients' perspectives on opioid tapering. DESIGN : Qualitative study using in-person, semistructured interviews. SETTING AND PATIENTS : English-speaking, adult primary care patients (N = 24) in three Colorado health care systems. METHODS : Interviews were audio recorded, transcribed, and analyzed in ATLAS.ti. We used a team-based, mixed inductive and deductive approach guided by the Health Belief Model. We iteratively refined emergent themes with input from a multidisciplinary team. RESULTS : Participants had a mean age of 52 years old, were 46% male and 79% white. Six participants (25%) were on COT and not tapering, 12 (50%) were currently tapering COT, and 6 (25%) had discontinued COT. Emergent themes were organized in four domains: risks, barriers, facilitators, and benefits. Patients perceived a low risk of overdose and prioritized the more immediate risk of increased pain with opioid tapering. Barriers included a perceived lack of effectiveness of nonopioid options and fear of opioid withdrawal. Among patients with opioid tapering experience, social support and a trusted health care provider facilitated opioid tapering. These patients endorsed improved quality of life following tapering. CONCLUSIONS : Efforts to support opioid tapering should elicit patients' perceived barriers and seek to build on relationships with family, peers, and providers to facilitate tapering. Future work should identify patient-centered, feasible strategies to support tapering of COT.

BackgroundColorectal cancer (CRC) diagnosed at ages <50 years old (early‐onset CRC) has been increasing in the United States, resulting in a growing number of early‐onset CRC survivors who may face significant financial and quality of life (QOL) challenges.ObjectiveIdentify themes from a patient advocate discussion about the impact of CRC on financial burden and QOL among early‐onset CRC survivors.MethodsWe conducted a semi‐structured, stakeholder discussion among 14 early‐onset CRC survivors and one caregiver who were members of an advocacy group. The discussion focused on the financial and overall QOL impacts of CRC. The meeting was recorded, transcribed and coded in ATLAS.ti, using a thematic analysis approach.ResultsCancer stage at diagnosis among advocates with CRC ranged from 2 to 4; about half of the attendees had no evidence of disease, and about half were undergoing treatment. Employment (career trajectory, lost wages, health insurance/benefits, performance) emerged as the dominant theme of the financial impacts discussion. Lifestyle impacts of disease and survivorship included both emotional and physical side‐effects. Diagnosis experience, missing information about CRC treatment and side‐effects, financial stress and strain on relationships were the primary themes for the overall QOL impacts.ConclusionGiven the growing incidence of CRC in those under 50, it is particularly important for providers to be aware of these patients' financial, emotional and QOL needs, and to develop care plans that specifically address these areas of concern for early‐onset CRC survivors.

Objective To determine the mortality attributable to smoking and years of potential life lost from smoking among people in prison and whether bans on smoking in prison are associated with reductions in smoking related deaths.Design Analysis of cross sectional survey data with the smoking attributable mortality, morbidity, and economic costs system; population based time series analysis.Setting All state prisons in the United States.Main outcome measures Prevalence of smoking from cross sectional survey of inmates in state correctional facilities. Data on state prison tobacco policies from web based searches of state policies and legislation. Deaths and causes of death in US state prisons from the deaths in custody reporting program of the Bureau of Justice Statistics for 2001-11. Smoking attributable mortality and years of potential life lost was assessed from the smoking attributable mortality, morbidity, and economic costs system of the Centers for Disease Control and Prevention. Multivariate Poisson models quantified the association between bans and smoking related cancer, cardiovascular and pulmonary deaths. ResultsThe most common causes of deaths related to smoking among people in prison were lung cancer, ischemic heart disease, other heart disease, cerebrovascular disease, and chronic airways obstruction. The age adjusted smoking attributable mortality and years of potential life lost rates were 360 and 5149 per 100 000, respectively; these figures are higher than rates in the general US population (248 and 3501, respectively). The number of states with any smoking ban increased from 25 in 2001 to 48 by 2011. In prisons the mortality rate from smoking related causes was lower during years with a ban than during years without a ban (110.4/100 000 v 128.9/100 000). Prisons that implemented smoking bans had a 9% reduction (adjusted incidence rate ratio 0.91, 95% confidence interval 0.88 to 0.95) in smoking related deaths. Bans in place for longer than nine years were associated with reductions in cancer mortality (adjusted incidence rate ratio 0.81, 95% confidence interval 0.74 to 0.90).Conclusions Smoking contributes to substantial mortality in prison, and prison tobacco control policies are associated with reduced mortality. These findings suggest that smoking bans have health benefits for people in prison, despite the limits they impose on individual autonomy and the risks of relapse after release.

Background Overdose Education and Naloxone Distribution (OEND) training for persons who inject drugs (PWID) underlines the importance of summoning emergency medical services (EMS). To encourage PWID to do so, Colorado enacted a Good Samaritan law providing limited immunity from prosecution for possession of a controlled substance and/or drug paraphernalia to the overdose victim and the witnesses who in good faith provide emergency assistance. This paper examines the law’s influence by describing OEND trained PWIDs’ experience reversing overdoses and their decision about calling for EMS support. Methods Findings from two complementary studies, a qualitative study based on semi-structured interviews with OEND trained PWID who had reversed one or more overdoses, and an on-going fieldwork-based project examining PWIDs’ self-identified health concerns were triangulated to describe and explain participants’ decision to call for EMS. Results In most overdose reversals described, no EMS call was made. Participants reported several reasons for not doing so. Most frequent was the fear that despite the Good Samaritan law, a police response would result in arrest of the victim and/or witness for outstanding warrants, or sentence violations. Fears were based on individual and collective experience, and reinforced by the city of Denver’s aggressive approach to managing homelessness through increased enforcement of misdemeanors and the imposition of more recent ordinances, including a camping ban, to control space. The city’s homeless crisis was reflected as well in the concern expressed by housed PWID that an EMS intervention would jeopardize their public housing. Conclusion Results suggest that the immunity provided by the Good Samaritan law does not address PWIDs’ fear that their current legal status as well as the victim’s will result in arrest and incarceration. As currently conceived, the Good Samaritan law does not provide immunity for PWIDs’ already enmeshed in the criminal justice system, or PWID fearful of losing their housing.

While discussing and implementing opioid tapering present significant challenges, primary care providers described key facilitators. These findings suggest a need to develop and test the effectiveness of resources to support patient-centered opioid tapering and locally developed policies to support and standardize providers' approaches to opioid prescribing.