Extreme Risk Protection Orders in Connecticut, 2013-2020.

Twenty-one states and the District of Columbia have enacted Extreme Risk Protection Order (ERPO) statutes, which allow temporary removal of firearms from individuals who pose an imminent risk of harm to themselves or others. Connecticut was the first state to enact such a law in 1999. The law's implementation and use between 1999 and 2013 were previously described, finding that ERPOs were pursued rarely for the first decade and that most orders were issued in response to concerns about suicide or self-harm rather than about interpersonal violence. The current study analyzes over 1,400 ERPOs in Connecticut between 2013 and 2020 in several domains: respondent demographics, circumstances leading to ERPO filing, type of threat (suicide, violence to others, or both), number and type of firearms removed, prevalence of mental illness and drug and alcohol use, and legal outcomes. Results are similar to the earlier study, indicating that ERPO respondents in Connecticut are primarily White, male, middle-aged residents of small towns and suburbs who pose a risk of harm to themselves (67.9%) more often than to others (42.8%). Significant gender differences between ERPO respondents are discussed, as are state-specific trends over time and differences between Connecticut and other states with published ERPO data.

Prescription Opioid Dose Change Prior to Fatal Opioid-Detected Overdose.

BACKGROUND: The opioid overdose crisis continues within the U.S., and the role of prescribed opioids and prescribing patterns in overdose deaths remains an important area of research. This study investigated patterns of prescription opioids dispensed in the 12 months prior to opioid-detected overdose death in Connecticut between May 8th, 2016 and January 2nd, 2018, considering differences by demographic characteristics. METHODS: The sample included decedents who had an opioid dispensed within 30 days preceding death. Using multilevel modeling, we estimated the slope of change in mean morphine equivalent (MME) daily dose over 12 months prior to death, considering linear and quadratic effects of time. We estimated the main effects of age, sex, race, and ethnicity and their interactions with time on MME. A sensitivity analysis examined how excluding decedents who did not receive long-term (≥90 days) opioid therapy affected mean MME slopes. Secondary analysis explored differences by toxicology results. RESULTS: Among 1,580 opioid-detected deaths, 179 decedents had prescribed opioids dispensed within 30 days preceding death. Decedents' mean age was 47.3 years (±11.5), 65.5% were male, 81% White non-Hispanic, 9.5% Black non-Hispanic, and 9.5% Hispanic. In the time-only model, linear (ß=6.25, p<0.01) and quadratic (ß=0.49, p=0.02) effects of time were positive, indicating exponentially increasing dose prior to death. Linear change in MME was significantly attenuated in men compared to women (ß=-4.87, p=0.03); however, men were more likely to have non-prescription opioids in their toxicology results (p=0.02). Sensitivity analysis results supported primary findings. CONCLUSION: Rapid dose increases in dispensed opioids may be associated with opioid-detected overdose deaths, especially among women.

A Dynamic Model for Estimating the Retention Duration of Neutralizing Antibody Titers After Vaccination in a COVID-19 Convalescent Population.

We measured neutralizing antibodies (nAbs) against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in a cohort of 235 convalescent patients (representing 384 analytic samples). They were followed for up to 588 days after the first report of onset in Taiwan. A proposed Bayesian approach was used to estimate nAb dynamics in patients postvaccination. This model revealed that the titer reached its peak (1819.70 IU/mL) by 161 days postvaccination and decreased to 154.18 IU/mL by day 360. Thus, the nAb titers declined in 6 months after vaccination. Protection, against variant B.1.1.529 (ie, Omicron) may only occur during the peak period.

Incarceration and screen-detectable cancer diagnosis among adults in Connecticut.

Although incarcerated adults are at elevated risk of dying from cancer, little is known about cancer screening in carceral settings. This study compared stage-specific incidence of screen-detectable cancers among incarcerated and recently released people with the general population, as a reflection of screening practices. We calculated the age- and sex-standardized incidence ratios (SIR) for early- and late-stage cancers for incarcerated and recently released adults compared to the general Connecticut population between 2005 and 2016. Our sample included 143 cancer cases among those incarcerated, 406 among those recently released, and 201 360 in the general population. The SIR for early-stage screen-detectable cancers was lower among incarcerated (SIR = 0.28, 95% CI = 0.17 to 0.43) and recently released (SIR = 0.69, 95% CI = 0.51 to 0.88) individuals than the general population. Incidence of late-stage screen-detectable cancer was lower during incarceration (SIR = 0.51, 95% CI = 0.27 to 0.88) but not after release (SIR = 1.32, 95% CI = 0.93 to 1.82). Findings suggest that underscreening and underdetection of cancer may occur in carceral settings.

The sleep justice study - a prospective cohort study assessing sleep as a cardiometabolic risk factor after incarceration: a protocol paper.

BACKGROUND: An estimated 11 million individuals are released from U.S. jails and prisons each year. Individuals with a history of incarceration have higher rates of cardiovascular disease (CVD) events and mortality compared to the general population, especially in the weeks following release from carceral facilities. Healthy sleep, associated with cardiovascular health, is an underexplored factor in the epidemiology of CVD in this population. Incarcerated people may have unique individual, environmental, and institutional policy-level reasons for being sleep deficient. The social and physical environment within carceral facilities and post-release housing may synergistically affect sleep, creating disparities in sleep and cardiovascular health. Since carceral facilities disproportionately house poor and minoritized groups, population-specific risk factors that impact sleep may also contribute to inequities in cardiovascular outcomes. METHODS: This study is ancillary to an ongoing prospective cohort recruiting 500 individuals with known cardiovascular risk factors within three months of release from incarceration, the Justice-Involved Individuals Cardiovascular Disease Epidemiology (JUSTICE) study. The Sleep Justice study will measure sleep health among participants at baseline and six months using three validated surveys: the Pittsburgh Sleep Quality Index (PSQI), the STOP-Bang, and the Brief Index of Sleep Control. In a subsample of 100 individuals, we will assess sleep over the course of one week using wrist actigraphy, a validated objective measure of sleep that collects data on rest-activity patterns, sleep, and ambient light levels. Using this data, we will estimate and compare sleep health and its association with CVD risk factor control in individuals recently released from carceral facilities. DISCUSSION: The incarceration of millions of poor and minoritized groups presents an urgent need to understand how incarceration affects CVD epidemiology. This study will improve our understanding of sleep health among people released from carceral facilities and its potential relationship to CVD risk factor control. Using subjective and objective measures of sleep will allow us to identify unique targets to improve sleep health and mitigate cardiovascular risk in an otherwise understudied population.

Cancer incidence among incarcerated and formerly incarcerated individuals: A statewide retrospective cohort study.

BACKGROUND: Cancer incidence among individuals with incarceration exposure has been rarely studied due to the absence of linked datasets. This study examined cancer incidence during incarceration and postincarceration compared to the general population using a statewide linked cohort. METHODS: We constructed a retrospective cohort from a linkage of state tumor registry and correctional system data for Connecticut residents from 2005 to 2016, and identified cancers diagnosed during and within 12 months postincarceration. We estimated incidence rates (including for screen-detectable cancers) and calculated the standardized incidence ratios (SIR) for the incarcerated and recently released populations, relative to the general population. We also examined cancer incidence by race and ethnicity within each group. RESULTS: Cancer incidence was lower in incarcerated individuals (SIR = 0.64, 95% CI 0.56-0.72), but higher in recently released individuals (SIR = 1.34, 95% CI 1.23-1.47) compared with the general population, and across all race and ethnic strata. Similarly, nonscreen-detectable cancer incidence was lower in incarcerated and higher in recently released populations compared to the general population. However, non-Hispanic Black individuals had elevated incidence of screen-detectable cancers compared with non-Hispanic White individuals across all three populations (incarcerated, SIR = 1.66, 95% CI 1.03-2.53; recently released, SIR = 1.83, 95% CI 1.32-2.47; and general population, SIR = 1.18, 95% CI 1.16-1.21). CONCLUSION: Compared with the general population, incarcerated persons have a lower cancer incidence, whereas recently released persons have a higher cancer incidence. Irrespective of incarceration status, non-Hispanic Black individuals have a higher incidence of screen-detectable cancers compared with non-Hispanic White individuals. Supplemental studies examining cancer screening and diagnoses during incarceration are needed to discern the reasons for observed disparities in incidence.

Concordance between controlled substance receipt and post-mortem toxicology in opioid-detected overdose deaths: A statewide analysis.

BACKGROUND: Opioid overdoses are a leading cause of preventable death in the United States. There is limited research linking decedents' receipt of controlled substances and presence of controlled substances on post-mortem toxicology (PMT). METHODS: We linked data on opioid-detected deaths in Connecticut between May 3, 2016, and December 31, 2017 from the Office of the Chief Medical Examiner, Department of Consumer Protection, and Department of Mental Health and Addiction Services. Exposure was defined as receipt of an opioid or benzodiazepine prescription within 90 days prior to death. Our primary outcome was concordance between medication received and metabolites in PMT. RESULTS: Our analysis included 1412 opioid-detected overdose deaths. 47 % received an opioid or benzodiazepine 90 days prior to death; 36 % received an opioid and 27 % received a benzodiazepine. Concordance between receipt of an opioid or benzodiazepine and its presence in PMT was observed in 30 % of opioid-detected deaths. Concordance with an opioid was present in 17 % of opioid-detected deaths and concordance with a benzodiazepine was present in 21 % of opioid-detected deaths. Receipt of an opioid or benzodiazepine and concordance with PMT were less common in fentanyl or heroin-detected deaths and more common in pharmaceutical opioid-detected deaths. DISCUSSION: Our results suggest medically supplied opioids and benzodiazepines potentially contributed to a substantial number, though minority, of opioid-detected deaths during the study period. Efforts to reduce opioid and benzodiazepine prescribing may reduce risk of opioid-detected deaths in this group, but other approaches will be needed to address most opioid-detected deaths that involved non-pharmaceutical opioids.

Incarceration status and cancer mortality: A population-based study.

BACKGROUND: The complex relationship between incarceration and cancer survival has not been thoroughly evaluated. We assessed whether cancer diagnosis during incarceration or the immediate post-release period is associated with higher rates of mortality compared with those never incarcerated. METHODS: We conducted a population-based study using a statewide linkage of tumor registry and correctional system movement data for Connecticut adult residents diagnosed with invasive cancer from 2005 through 2016. The independent variable was place of cancer diagnosis: during incarceration, within 12 months post-release, and never incarcerated. The dependent variables were five-year cancer-related and overall survival rates. RESULTS: Of the 216,540 adults diagnosed with invasive cancer during the study period, 239 (0.11%) people were diagnosed during incarceration, 479 (0.22%) within 12 months following release, and the remaining were never incarcerated. After accounting for demographics and cancer characteristics, including stage of diagnosis, the risk for cancer-related death at five years was significantly higher among those diagnosed while incarcerated (AHR = 1.39, 95% CI = 1.12-1.73) and those recently released (AHR = 1.82, 95% CI = 1.57-2.10) compared to the never-incarcerated group. The risk for all-cause mortality was also higher for those diagnosed with cancer while incarcerated (AHR = 1.92, 95% CI = 1.63-2.26) and those recently released (AHR = 2.18, 95% CI = 1.94-2.45). CONCLUSIONS AND RELEVANCE: There is a higher risk of cancer mortality among individuals diagnosed with cancer during incarceration and in the first-year post-release, which is not fully explained by stage of diagnosis. Cancer prevention and treatment efforts should target people who experience incarceration and identify why incarceration is associated with worse outcomes.

Cost savings of a primary care program for individuals recently released from prison: a propensity-matched study.

BACKGROUND: Criminal justice system costs in the United States have exponentially increased over the last decades, and providing health care to individuals released from incarceration is costly. To better understand how to manage costs to state budgets for those who have been incarcerated, we aimed to assess state-level costs of an enhanced primary care program, Transitions Clinic Network (TCN), for chronically-ill and older individuals recently released from prison. METHODS: We linked administrative data from Connecticut Department of Correction, Medicaid, and Department of Mental Health and Addiction Services to identify a propensity matched comparison group and estimate costs of a primary care program serving chronically-ill and older individuals released from incarceration between 2013 and 2016. We matched 94 people released from incarceration who received care at a TCN program to 94 people released from incarceration who did not receive care at TCN program on numerous characteristics. People eligible for TCN program participation were released from incarceration within the prior 6 months and had a chronic health condition or were over the age of 50. We estimated 1) costs associated with the TCN program and 2) costs accrued by Medicaid and the criminal justice system. We evaluated associations between program participation and Medicaid and criminal justice system costs over a 12-month period using bivariate analyses with nonparametric bootstrapping method. RESULTS: The 12-month TCN program operating cost was estimated at $54,394 ($146 per participant per month). Average monthly Medicaid costs per participant were not statistically different between the TCN ($1737 ± $3449) and comparison ($1356 ± $2530) groups. Average monthly criminal justice system costs per participant were significantly lower among TCN group ($733 ± $1130) compared with the matched group ($1276 ± $1738, p < 0.05). We estimate every dollar invested in the TCN program yielded a 12-month return of $2.55 to the state. CONCLUSIONS: Medicaid investments in an enhanced primary care program for individuals returning from incarceration are cost neutral and positively impact state budgets by reducing criminal justice system costs.

A prospective cohort study examining exposure to incarceration and cardiovascular disease (Justice-Involved Individuals Cardiovascular Disease Epidemiology - JUSTICE study): a protocol paper.

BACKGROUND: People who have been incarcerated have high rates of cardiovascular risk factors, such as hypertension and smoking, and cardiovascular disease (CVD) is a leading cause of hospitalizations and mortality in this population. Despite this, little is known regarding what pathways mediate the association between incarceration exposure and increased rates of CVD morbidity and especially what incarceration specific factors are associated with this risk. The objective of this study is to better understand CVD risk in people exposed to incarceration and the pathways by which accumulate cardiovascular risk over time. METHODS AND ANALYSIS: The Justice-Involved Individuals Cardiovascular Disease Epidemiology (JUSTICE) study is a prospective cohort study of individuals released from incarceration with known cardiovascular risk factors. We are recruiting 500 individuals within three months after release from jail/prison. At baseline we are assessing traditional risk factors for CVD, including diet, exercise, and smoking, and exposure to incarceration-related policies, psychosocial stress, and self-efficacy. Cardiovascular risk factors are measured at baseline through point of care testing. We are following these individuals for the 12 months following the index release from incarceration with re-evaluation of psychosocial factors and clinical risk factors every 6 months. Using these data, we will estimate the direct and indirect latent effects of incarceration on cardiovascular risk factors and the paths via which these effects are mediated. We will also model the anticipated 10-year burden of CVD incidence, health care use, and mortality associated with incarceration. DISCUSSION: Our study will identify factors associated with CVD risk factor control among people released from incarceration. Our measurement of incarceration-related exposures, psychosocial factors, and clinical measures of cardiovascular risk will allow for identification of unique targets for intervention to modify CVD risk in this vulnerable population.

Identification and management of contraindicated drug-drug interactions through pharmaceutical care programs: Experience in direct-acting antivirals therapy.

BACKGROUND/PURPOSE: To investigate the impact of pharmaceutical care programs for the management of contraindicated drug-drug interactions (DDIs) in direct-acting antivirals (DAAs) therapy. METHODS: A prospective observational study was performed at Dalin Tzu Chi Hospital between January 2018 and December 2019. Pharmacists screened DDIs for all hepatitis C patients before DAA therapy. The study outcome included the frequency of contraindicated DDIs, acceptance rate, and cost avoidance of the pharmaceutical care program. RESULTS: A total of 1053 patients were enrolled in the study, with a mean age of 67.1 ± 11.9 years. Most patients received therapy with sofosbuvir/ledipasvir (37.1%; n = 391), elbasvir/grazoprevir (23.8%; n = 251), or glecaprevir/pibrentasvir (21.1%; n = 222). A total of 796 (75.6%) patients received at least one co-medication, with the average number of co-medications being 5.2 per patient (SD: 4.4/patient). In total, 1356 DDIs were identified, with the average DDIs per patient of 1.3 (SD: 1.7). For patients with contraindicated DDIs (2%, n = 102), statins and amiodarone were the most common co-medications. Physicians often accepted pharmacists' recommendations (acceptance rate of 72.5%) or withheld co-medication to avoid severe adverse drug events (ADEs). The estimated cost avoidance of preventable ADEs was USD 14,033 for contraindicated DDIs with pharmaceutical care programs. CONCLUSION: The implementation of pharmaceutical care programs in DAA therapy provides a favorable outcome and substantial cost avoidance.

Incarceration and Cancer-Related Outcomes (ICRO) study protocol: using a mixed-methods approach to investigate the role of incarceration on cancer incidence, mortality and quality of care.

INTRODUCTION: Incarceration is associated with decreased cancer screening rates and a higher risk for hospitalisation and death from cancer after release from prison. However, there is a paucity of data on the relationship between incarceration and cancer outcomes and quality of care. In the Incarceration and Cancer-Related Outcomes Study, we aim to develop a nuanced understanding of how incarceration affects cancer incidence, mortality and treatment, and moderates the relationship between socioeconomic status, structural racism and cancer disparities. METHODS AND ANALYSIS: We will use a sequential explanatory mixed-methods study design. We will create the first comprehensive linkage of data from the Connecticut Department of Correction and the statewide Connecticut Tumour Registry. Using the linked dataset, we will examine differences in cancer incidence and stage at diagnosis between individuals currently incarcerated, formerly incarcerated and never incarcerated in Connecticut from 2005 to 2016. Among individuals with invasive cancer, we will assess relationships among incarceration, quality of cancer care and mortality, and will assess the degree to which incarceration status moderates relationships among race, socioeconomic status, quality of cancer care and cancer mortality. We will use multivariable logistic regression and Cox survival models with interaction terms as appropriate. These results will inform our conduct of in-depth interviews with individuals diagnosed with cancer during or shortly after incarceration regarding their experiences with cancer care in the correctional system and the immediate postrelease period. The results of this qualitative work will help contextualise the results of the data linkage. ETHICS AND DISSEMINATION: The Yale University Institutional Review Board (#2000022899) and the Connecticut Department of Public Health Human Investigations Committee approved this study. We will disseminate study findings through peer-reviewed publications and academic and community presentations. Access to the deidentified quantitative and qualitative datasets will be made available on review of the request.

The Transitions Clinic Network: Post Incarceration Addiction Treatment, Healthcare, and Social Support (TCN-PATHS): A hybrid type-1 effectiveness trial of enhanced primary care to improve opioid use disorder treatment outcomes following release from jail.

BACKGROUND: In 2016, at least 20% of people with opioid use disorder (OUD) were involved in the criminal justice system, with the majority of individuals cycling through jails. Opioid overdose is the leading cause of death and a common cause of morbidity after release from incarceration. Medications for OUD (MOUD) are effective at reducing overdoses, but few interventions have successfully engaged and retained individuals after release from incarceration in treatment. OBJECTIVE: To assess whether follow-up care in the Transitions Clinic Network (TCN), which provides OUD treatment and enhanced primary care for people released from incarceration, improves key measures in the opioid treatment cascade after release from jail. In TCN programs, primary care teams include a community health worker with a history of incarceration, and they attend to social needs, such as housing, food insecurity, and criminal legal system contact, along with patients' medical needs. METHODS AND ANALYSIS: We will bring together six correctional systems and community health centers with TCN programs to conduct a hybrid type-1 effectiveness/implementation study among individuals who were released from jail on MOUD. We will randomize 800 individuals on MOUD released from seven local jails (Bridgeport, CT; Niantic, CT; Bronx, NY; Caguas, PR; Durham, NC; Minneapolis, MN; Ontario County, NY) to compare the effectiveness of a TCN intervention versus referral to standard primary care to improve measures within the opioid treatment cascade. We will also determine what social determinants of health are mediating any observed associations between assignment to the TCN program and opioid treatment cascade measures. Last, we will study the cost effectiveness of the approach, as well as individual, organizational, and policy-level barriers and facilitators to successfully transitioning individuals on MOUD from jail to the TCN. ETHICS AND DISSEMINATION: Investigation Review Board the University of North Carolina (IRB Study # 19-1713), the Office of Human Research Protections, and the NIDA JCOIN Data Safety Monitoring Board approved the study. We will disseminate study findings through peer-reviewed publications and academic and community presentations. We will disseminate study data through a web-based platform designed to share data with TCN PATHS participants and other TCN stakeholders. Clinical trials.gov registration: NCT04309565.

Merging statewide data in a public/university collaboration to address opioid use disorder and overdose.

OBJECTIVE: Describe methods to compile a unified database from disparate state agency datasets linking person-level data on controlled substance prescribing, overdose, and treatment for opioid use disorder in Connecticut. METHODS: A multidisciplinary team of university, state and federal agency experts planned steps to build the data analytic system: stakeholder engagement, articulation of metrics, funding to establish the system, determination of needed data, accessing data and merging, and matching patient-level data. RESULTS: Stakeholder meetings occurred over a 6-month period driving selection of metrics and funding was obtained through a grant from the Food and Drug Administration. Through multi-stakeholder collaborations and memoranda of understanding, we identified relevant data sources, merged them and matched individuals across the merged dataset. The dataset contains information on sociodemographics, treatments and outcomes. Step-by-step processes are presented for dissemination. CONCLUSIONS: Creation of a unified database linking multiple sources in a timely and ongoing fashion may assist other states to monitor the public health impact of controlled substances, identify and implement interventions, and assess their effectiveness.

Gender-specific participation and outcomes among jail diversion clients with co-occurring substance use and mental health disorders.

Men and women with co-occurring substance use disorders and mental illness are at relatively high risk for becoming involved in the criminal justice system. Programs, such as post-booking jail diversion, aim to connect these individuals to community-based treatment services in lieu of pursuing criminal prosecution. Gender appears to have an important influence on risk factors and pathways through the criminal justice system, which in turn may influence how interventions like jail diversion work to engage men and women in treatment services and reduce recidivism. Different circumstances, levels of engagement, and outcomes by gender may be related to both person-level characteristics and external factors such as availability of gender-specific services and resources. This mixed-methods study identified specific ways in which men and women use services and reoffend after being diverted, and complemented those findings with in-depth insights from program clinicians about how program experiences and resources differ in important ways by gender. We matched and merged administrative records from 2007 to 2009 for 16,233 adults from several state agencies in Connecticut, and included data on demographic characteristics, clinical diagnoses, outpatient and inpatient behavioral health treatment utilization, arrest, and incarceration. Using propensity analysis, the 1693 men and women who participated in the statewide jail diversion program were matched to respective comparison groups of nondiverted men and women. We used longitudinal multivariable regression analyses to estimate the effects of jail diversion participation on treatment utilization, arrest, and incarceration, separately for men and women. We conducted three focus groups with jail diversion clinicians from around the state (n = 21) to gain in-depth insight from them about how circumstances, program experiences, and resources differ by gender in important ways; these subjective clinician insights complement the quantitative analyses of diversion outcomes for men and women. For both men and women, diversion was associated with reductions in risk for incarceration and increases in utilization of outpatient treatment services. For men only, diversion was associated with higher utilization of inpatient mental health care. No differences in treatment or criminal justice outcomes were observed in models that compared men and women directly. Major themes from the focus groups included: the existence of too few inpatient and residential resources for women with co-occurring disorders; different challenges to treatment engagement that men and women face; and a need for more effective, gender-specific services for all program participants. Results from this mixed-methods study offer information on gender-specific program outcomes and surrounding circumstances that can help programs to better understand and address unique risks and needs for men and women with co-occurring substance use and mental health disorders who are involved in the criminal justice system.

Impact of Mobile Crisis Services on Emergency Department Use Among Youths With Behavioral Health Service Needs.

OBJECTIVE: Youths are using emergency departments (EDs) for behavioral health services in record numbers, even though EDs are suboptimal settings for service delivery. In this article, the authors evaluated a mobile crisis service intervention implemented in Connecticut with the aim of examining whether the intervention was associated with reduced behavioral health ED use among those in need of services. METHODS: The authors examined two cohorts of youths: 2,532 youths who used mobile crisis services and a comparison sample of 3,961 youths who used behavioral health ED services (but not mobile crisis services) during the same fiscal year. Propensity scores were created to balance the two groups, and outcome analyses were used to examine subsequent ED use (any behavioral health ED admissions and number of behavioral health ED admissions) in an 18-month follow-up period. RESULTS: A pooled odds ratio of 0.75 (95% confidence interval [CI]=0.66-0.84) indicated that youths who received mobile crisis services had a significant reduction in odds of a subsequent behavioral health ED visit compared with youths in the comparison sample. The comparable result for the continuous outcome of number of behavioral health ED visits yielded an incidence risk ratio of 0.78 (95% CI=0.71-0.87). CONCLUSIONS: Using comparison groups, the authors provided evidence suggesting that community-based mobile crisis services, such as Mobile Crisis, reduce ED use among youths with behavioral health service needs. Replication in other years and locations is needed. Nevertheless, these results are quite promising in light of current trends in ED use.

Propensity-matched study of enhanced primary care on contact with the criminal justice system among individuals recently released from prison to New Haven.

BACKGROUND: Health systems can be integral to addressing population health, including persons with incarceration exposure. Few studies have comprehensively integrated state-wide data to assess how the primary care system can impact criminal justice outcomes. We examined whether enhanced primary care can decrease future contact with the criminal justice system among individuals just released from prison. METHODS: We linked administrative data (2013-2016) of Connecticut Department of Correction, Department of Mental Health and Addiction Services, Department of Social Service, Court Support Services Division, and Department of Public Health to conduct a quasi-experimental study using propensity score matching of 94 participants who received enhanced primary care in Transitions Clinic to 94 controls not exposed to the programme. The propensity score included 23 variables, which encompassed participants' medical and incarceration history and service utilisation. The main outcomes were reincarceration rates and days incarcerated in the first year from the index date, which was either enrolment in the Transitions Clinic programme or release from prison in the control group. RESULTS: The odds of reincarceration, including arrests and new convictions, were similar for the two groups, but Transitions Clinic participants had lower odds of returning to prison for a parole or probation technical violation (adjusted OR: 0.38; 95% CI 0.16 to 0.93) compared with the control group. Further, Transitions Clinic participants had fewer incarceration days (incidence rate ratio: 0.55; 95% CI 0.35 to 0.84) compared with the control group. CONCLUSIONS: Enhanced primary care for individuals just released from prison can reduce reincarceration for technical violations and shorten time spent within correctional facilities. This study shows how community health systems may play a role in current strategies to reduce prison populations.

Criminal Justice and Suicide Outcomes with Indiana's Risk-Based Gun Seizure Law.

This article examines the application and effectiveness of a 2006 Indiana law designed to prevent gun violence by authorizing police officers to separate firearms from persons who present imminent or future risk of injury to self or others, or display a propensity for violent or emotionally unstable conduct. A court hearing is held to determine ongoing risk in these cases; a judge decides whether to return the seized firearms or retain them for up to five years. The study examines the frequency of criminal arrest as well as suicide outcomes for 395 gun-removal actions in Indiana. Fourteen individuals (3.5%) died from suicide, seven (1.8%) using a firearm. The study population's annualized suicide rate was about 31 times higher than that of the general adult population in Indiana, demonstrating that the law is being applied to a population genuinely at high risk. By extrapolating information on the case fatality rate for different methods of suicide, we calculated that one life was saved for every 10 gun-removal actions, similar to results of a previous study in Connecticut. Perspectives from key stakeholders are also presented along with implications for gun policy reform and implementation.

Associations between pharmacotherapy for opioid dependence and clinical and criminal justice outcomes among adults with co-occurring serious mental illness.

Adults suffering from a serious mental illness (SMI) and a substance use disorder are at especially high risk for poor clinical outcomes and also arrest and incarceration. Pharmacotherapies for treating opioid dependence could be a particularly important mode of treatment for opioid-dependent adults with SMI to lower their risk for overdose, high-cost hospitalizations, repeated emergency department visits, and incarceration, given relapse rates are very high following detoxification in the absence of one of the three FDA-approved pharmacotherapies. This study estimates the effects of methadone, buprenorphine, and oral naltrexone on clinical and justice-related outcomes in a sample of justice-involved adults with SMI, opioid dependence, and criminal justice involvement. Administrative data were merged from several public agencies in Connecticut for 8736 adults 18years of age or older with schizophrenia spectrum disorder, bipolar disorder, or major depression; co-occurring moderate to severe opioid dependence; and who also had at least one night in jail during 2002-2009. Longitudinal multivariable regression models estimated the effect of opioid-dependence pharmacotherapy as compared to outpatient substance abuse treatment without opioid-dependence pharmacotherapy on inpatient substance abuse or mental health treatment, emergency department visits, criminal convictions, and incarcerations, analyzing instances of each outcome 12months before and after an index treatment episode. Several baseline differences between the study groups (opioid-dependence pharmacotherapy group versus outpatient treatment without opioid-dependence pharmacotherapy) were adjusted for in the regression models. All three opioid-dependence pharmacotherapies were associated with reductions in inpatient substance abuse treatment, and among the oral naltrexone subgroup, also reductions in inpatient mental health treatment, as well as improved adherence to SMI medications. Overall, the opioid-dependence pharmacotherapy group had higher rates of arrest and incarceration in the follow-up period than the comparison group; but those using oral naltrexone had lower rates of arrest (including felonies). The analysis of observational administrative data provides useful population-level estimates but also has important limitations that preclude conclusive causal inferences. Large reductions in crisis-driven service utilization associated with opioid-dependence pharmacotherapy in this study suggest that evidence-based medications for treating opioid dependence can be used successfully in adults with SMI and should be considered more systematically during assessments of treatment needs for this population.

Evaluation of CT's ASIST program: Specialized services to divert higher risk defendants.

Some criminal defendants with mental illness may not be referred to traditional mental health jail diversion programs because they have a history of non-compliance with treatment, or complex personal circumstances such as homelessness. To successfully divert such individuals, Connecticut has developed a specialized program called the Advanced Supervision and Intervention Support Team (ASIST), which offers criminal justice supervision in conjunction with mental health treatment and support services. An evaluation of the ASIST program included a six-month follow-up study of 111 program clients to examine mental health functioning and other outcomes, and a comparison of administrative data for 492 ASIST clients with a propensity-matched group to examine recidivism. Follow-up study clients showed improvements in mental health. Administrative data showed no change in arrest rates, but a significant reduction in re-incarceration. These findings must be viewed with caution due to the quasi-experimental design of the study, but it appears that greater attention to criminogenic needs in addition to defendants' mental illness may help jurisdictions to divert a wider variety of defendants.