Share of Adult Suicides After Recent Jail Release.

Importance: Although people released from jail have an elevated suicide risk, the potentially large proportion of this population in all adult suicides is unknown. Objective: To estimate what percentage of adults who died by suicide within 1 year or 2 years after jail release could be reached if the jail release triggered community suicide risk screening and prevention efforts. Design, Setting, and Participants: This cohort modeling study used estimates from meta-analyses and jail census counts instead of unit record data. The cohort included all adults who were released from US jails in 2019. Data analysis and calculations were performed between June 2021 and February 2024. Main Outcomes and Measures: The outcomes were percentage of total adult suicides within years 1 and 2 after jail release and associated crude mortality rates (CMRs), standardized mortality ratios (SMRs), and relative risks (RRs) of suicide in incarcerated vs not recently incarcerated adults. Taylor expansion formulas were used to calculate the variances of CMRs, SMRs, and other ratios. Random-effects restricted maximum likelihood meta-analyses were used to estimate suicide SMRs in postrelease years 1 and 2 from 10 jurisdictions. Alternate estimate was computed using the ratio of suicides after release to suicides while incarcerated. Results: Included in the analysis were 2019 estimates for 7 091 897 adults (2.8% of US adult population; 76.7% males and 23.3% females) who were released from incarceration at least once, typically after brief pretrial stays. The RR of suicide was 8.95 (95% CI, 7.21-10.69) within 1 year after jail release and 6.98 (95% CI, 4.21-9.76) across 2 years after release. A total of 27.2% (95% CI, 18.0%-41.7%) of all adult suicide deaths occurred in formerly incarcerated individuals within 2 years of jail release, and 19.9% (95% CI, 16.2%-24.1%) of all adult suicides occurred within 1 year of release (males: 23.3% [95% CI, 20.8%-25.6%]; females: 24.0% [95% CI, 19.7%-36.8%]). The alternate method yielded slightly larger estimates. Another 0.8% of adult suicide deaths occurred during jail stays. Conclusions and Relevance: This cohort modeling study found that adults who were released from incarceration at least once make up a large, concentrated population at greatly elevated risk for death by suicide; therefore, suicide prevention efforts focused on return to the community after jail release could reach many adults within 1 to 2 years of jail release, when suicide is likely to occur. Health systems could develop infrastructure to identify these high-risk adults and provide community-based suicide screening and prevention.

Disease burden of adverse childhood experiences across 14 states.

OBJECTIVE: To examine whether the relationship between Adverse Childhood Experiences (ACEs) and health outcomes is similar across states and persists net of ACEs associations with smoking, heavy drinking, and obesity. METHODS: We use data from the Behavioral Risk Factor Surveillance System for 14 states. Logistic regressions yield estimates of the direct associations of ACEs exposure with health outcomes net of health risk factors, and indirect ACEs-health associations via health risk factors. Models were estimated for California (N = 22,475) and pooled data from 13 states (N = 110,076), and also separately by state. RESULTS: Exposure to ACEs is associated with significantly higher odds of smoking, heavy drinking, and obesity. Net of these health risk factors, there was a significant and graded relationship in California and the pooled 13-state data between greater ACEs exposure and odds of depression, asthma, COPD, arthritis, and cardiovascular disease. Four or more ACEs were less consistently associated across states with cancer and diabetes and a dose-response relationship was also not present. There was a wide range across individual states in the percentage change in health outcomes predicted for exposure to 4+ ACEs. ACEs-related smoking, heavy drinking, and obesity explain a large and significant proportion of 4+ ACEs associations with COPD and cardiovascular disease, however some effect, absent of risk behavior, remained. CONCLUSIONS: ACE's associations with most of the health conditions persist independent of behavioral pathways but only asthma, arthritis, COPD, cardiovascular disease, and depression consistently exhibit a dose-response relationship. Our results suggest that attention to child maltreatment and household dysfunction, mental health treatment, substance abuse prevention and promotion of physical activity and healthy weight outcomes might mitigate some adverse health consequences of ACEs. Differences across states in the pattern of ACEs-health associations may also indicate fruitful areas for prevention.

Adult health burden and costs in California during 2013 associated with prior adverse childhood experiences.

OBJECTIVES: To estimate the adult health burden and costs in California during 2013 associated with adults' prior Adverse Childhood Experiences (ACEs). METHODS: We analyzed five ACEs-linked conditions (asthma, arthritis, COPD, depression, and cardiovascular disease) and three health risk factors (lifetime smoking, heavy drinking, and obesity). We estimated ACEs-associated fractions of disease risk for people aged 18+ for these conditions by ACEs exposure using inputs from a companion study of California Behavioral Risk Factor Surveillance System data for 2008-2009, 2011, and 2013. We combined these estimates with published estimates of personal healthcare spending and Disability-Adjusted-Life-Years (DALYs) in the United States by condition during 2013. DALYs captured both the years of healthy life lost to disability and the years of life lost to deaths during 2013. We applied a published estimate of cost per DALY. RESULTS: Among adults in California, 61% reported ACEs. Those ACEs were associated with $10.5 billion in excess personal healthcare spending during 2013, and 434,000 DALYs valued at approximately $102 billion dollars. During 2013, the estimated health burden per exposed adult included $589 in personal healthcare expenses and 0.0224 DALYs valued at $5,769. CONCLUSIONS: Estimates of the costs of childhood adversity are far greater than previously understood and provide a fiscal rationale for prevention efforts.

Employee assistance programs, drug testing, and workplace injury.

INTRODUCTION: Little is known about the effects of employee assistance programs (EAPs) on occupational injuries. MATERIALS AND METHODS: Multivariate regressions probed a unique data set that linked establishment information about workplace anti-drug programs in 1988 with occupational injury rates for 1405 establishments. RESULTS: EAPs were associated with a significant reduction in both no-lost-work and lost-work injuries, especially in the manufacturing and transportation, communication and public utilities industries (TCPU). Lost-work injuries were more responsive to specific EAP characteristics, with lower rates associated with EAPs staffed by company employees (most likely onsite). Telephone hotline services were associated with reduced rates of lost-work injuries in manufacturing and TCPU. Drug testing was associated with reductions in the rate of minor injuries with no lost work, but had no significant relationship with lost-work injuries. PRACTICAL APPLICATIONS: This associational study suggests that EAPs, especially ones that are company-staffed and ones that include telephone hotlines, may prevent workplace injuries.

Substance-use problems: are uninsured workers at greater risk?

OBJECTIVE: This study examined how problem drinking and drug use and their related treatment received by workers varied by health insurance coverage and employment characteristics. METHOD: We used National Survey on Drug Use and Health data on civilian workers ages 18 years and older from the 2002 and 2003 public-use files. Multivariate logistic regressions estimated the relationship between workers' uninsured status and problem use, dependence, and treatment while controlling for worker demographics, education, income, and job characteristics. RESULTS: Controlling for differences in worker and workplace characteristics, uninsured workers were significantly more likely than privately insured workers to be illicit drug users or heavy drinkers. Among dependent workers, the lack of insurance was associated with a reduction in treatment received for problem drinkers (odds ratio = 0.31, p = .13). By contrast, a large, positive-albeit statistically nonsignificant-association between being uninsured and receiving treatment prevailed among uninsured workers using illicit drugs. Workplace substance-use policies were associated with a significant reduction in the odds of treatment received or treatment needed among problem drinkers without insurance coverage. Employee assistance programs were not good predictors of treatment received among uninsured workers. CONCLUSIONS: Uninsured workers were more likely to be heavy drinkers or illicit drug users than were workers with health insurance. Health insurance coverage was not significantly associated with treatment received among workers reporting problem use. Uninsured workers may be unable to benefit fully from employee assistance programs' treatment and referral services, whose utility depends on adequate behavioral health coverage for workers.

Occupational injury costs and alternative employment in construction trades.

OBJECTIVE: To present the costs of fatal and non-fatal days-away-from-work injuries in 50 construction occupations. Our results also provide indirect evidence on the cost exposure of alternative construction workers such as independent contractors, on-call or day labor, contract workers, and temporary workers. METHODS: We combine data from the Bureau of Labor Statistics on average annual incidence from 2000 to 2002 with updated per-case costs from an existing cost model for occupational injuries. The Current Population Survey provides data on the percentage of alternative construction workers. RESULTS: Construction laborers and carpenters were the two costliest occupations, with 40% of the industry's injury costs. The 10 costliest construction occupations also have a high percentage of alternative workers. CONCLUSIONS: The construction industry has both a high rate of alternative employment and high costs of work injury. Alternative workers, often lacking workers' compensation, are especially exposed to injury costs.

Costs of occupational injuries in construction in the United States.

This paper presents costs of fatal and nonfatal injuries for the construction industry using 2002 national incidence data from the Bureau of Labor Statistics and a comprehensive cost model that includes direct medical costs, indirect losses in wage and household productivity, as well as an estimate of the quality of life costs due to injury. Costs are presented at the three-digit industry level, by worker characteristics, and by detailed source and event of injury. The total costs of fatal and nonfatal injuries in the construction industry were estimated at $11.5 billion in 2002, 15% of the costs for all private industry. The average cost per case of fatal or nonfatal injury is $27,000 in construction, almost double the per-case cost of $15,000 for all industry in 2002. Five industries accounted for over half the industry's total fatal and nonfatal injury costs. They were miscellaneous special trade contractors (SIC 179), followed by plumbing, heating and air-conditioning (SIC 171), electrical work (SIC 173), heavy construction except highway (SIC 162), and residential building construction (SIC 152), each with over $1 billion in costs.

Random alcohol testing reduced alcohol-involved fatal crashes of drivers of large trucks.

OBJECTIVE: This study examined the impact of random alcohol testing, implemented on August 1, 1994, on the likelihood that the driver of a large truck involved in a fatal motor vehicle crash was alcohol-involved. METHOD: Among fatal crashes, the proportion of alcohol-positive large truck drivers (intervention group) was compared with the proportion of alcohol-positive light passenger vehicle drivers (control group). Annual Fatality Analysis Reporting System (FARS) data (1988-2003) were compiled for each of the 50 states and Washington, D.C., for the control and intervention groups. Using these pooled cross-sectional data, logistic regression modeled the likelihood that a driver was alcohol-positive (blood alcohol concentration > 0) before compared with after random alcohol testing. We attributed the difference-in-difference (the difference in likelihoods of being alcohol positive pretesting versus post-testing in large truck versus passenger vehicle drivers) to the impact of random testing. RESULTS: Drivers of large trucks were 18.6% less likely to be alcohol-involved after random testing was implemented than before random testing (odds ratio [OR] = 0.814, 95% confidence interval [CI]: 0.713-0.930). The control group of passenger car drivers was 4.7% less likely to be alcohol-involved after random testing was implemented (OR = 0.953, 95% CI: 0.924-0.983). The net reduction in the odds of alcohol involvement for drivers of large trucks was 14.5% (OR = 0.855, 95% CI: 0.748-0.976). CONCLUSIONS: Controlling for the general declining trend in alcohol-involved drivers in fatal crashes, random alcohol testing was correlated with a 14.5% reduction in alcohol involvement among large truck drivers.

Substance abuse and the uninsured worker in the United States.

Although millions of US workers lack health insurance, the relationship of insurance coverage with substance abuse and access to workplace treatment services remains unexplored. Our analysis shows uninsured workers have higher rates of heavy drinking and illicit drug use than insured workers. Young and part-time workers are, moreover, less likely to have insurance coverage than workers with lower substance abuse risks. Compared to the insured, uninsured workers have less access to employee assistance programs (EAPs) and less drug and alcohol testing by employers. The effectiveness of workplace substance abuse programs and policies designed for insured populations is untested among uninsured workers. Issues include EAP effectiveness with referrals to public treatment and the return on investment for adding coverage of substance abuse treatment. Workers in countries with universal health insurance but inadequate treatment capacity may face similar problems to uninsured workers in the US.