Hospital Use and Mortality Among Decarcerated Individuals With Substance Use Disorder After a Large-scale COVID-19 Emergency Prison Release Program.

This cohort study examines hospital use and mortality among persons with substance use disorder (SUD) who were released from New Jersey state prisons after a COVID-19 emergency prison release program.

Long-acting buprenorphine vs. naltrexone opioid treatments in CJS-involved adults (EXIT-CJS).

The EXIT-CJS (N = 1005) multisite open-label randomized controlled trial will compare retention and effectiveness of extended-release buprenorphine (XR-B) vs. extended-release naltrexone (XR-NTX) to treat opioid use disorder (OUD) among criminal justice system (CJS)-involved adults in six U.S. locales (New Jersey, New York City, Delaware, Oregon, Connecticut, and New Hampshire). With a pragmatic, noninferiority design, this study hypothesizes that XR-B (n = 335) will be noninferior to XR-NTX (n = 335) in retention-in-study-medication treatment (the primary outcome), self-reported opioid use, opioid-positive urine samples, opioid overdose events, and CJS recidivism. In addition, persons with OUD not eligible or interested in the RCT will be recruited into an enhanced treatment as usual arm (n = 335) to examine usual care outcomes in a quasi-experimental observational cohort.

Criminal Recidivism in Inmates with Mental Illness and Substance Use Disorders.

The relative contributions of mental illness and substance use disorders to criminal recidivism have important clinical and policy implications. This study reviewed 36 months of postrelease data for nearly 10,000 New Jersey state inmates released in 2013 to ascertain the rearrest rate of those diagnosed with mental illness, substance use disorders, both, or neither. We also examined whether certain characteristics suggestive of higher risk of psychiatric decompensation were associated with higher rates of rearrest. Released inmates who were diagnosed with a substance use disorder (without a mental illness) while incarcerated had the highest rate of rearrest upon release, followed by inmates diagnosed with both mental illness and substance use disorder together, inmates with neither a substance use disorder nor a mental illness, and lastly by inmates diagnosed with mental illness alone. These differences were statistically significant only between inmates with substance use disorders and those without a substance use disorder. Among those with a diagnosed mental disorder, there were no statistically significant differences in recidivism based on diagnosis or based on prescription of antipsychotic medication, injectable antipsychotic medication, or involuntary antipsychotic medication. These results support correctional institutions assertively addressing substance use disorders, especially for individuals returning to the community.

Characteristics of Inmates Who Misuse Prescription Medication.

Substance use disorders are common among incarcerated individuals, and prescribed medications have been reported as abused, diverted, or otherwise misused in correctional settings. We conducted a retrospective chart review of electronic medical records and reports on institutional charges for misuse of authorized medication by inmates in the New Jersey Department of Corrections between 2003 and 2013. The most frequently cited medications for misuse were gabapentin, diphenhydramine, clonidine, and ibuprofen. When compared with the entire current inmate population, subjects were more likely to have any history of a substance use disorder, to be in treatment for a mental illness, to have any diagnosis of antisocial personality disorder, to have any history of malingering, and to be prescribed a greater number of medicines. Prescribers in correctional settings should be aware that medications not traditionally prescribed by a psychiatrist may also be misused, and caution should be taken to manage this risk.

Characteristics of Inmates Who Initiate Hunger Strikes.

A hunger strike is a common, expensive, and potentially lethal event within a correctional institution. In this study, we describe the characteristics of inmates who initiated hunger strikes in a state prison system. Electronic medical records for a state prison system were reviewed for documentation of hunger strikes from January 2005 through September 2015. There were 292 hunger strikes during the study period. Most (71%) lasted three or fewer days. When weight data were available, only 12.9 percent of the hunger strikes resulted in a weight loss >10 percent. Mental health patients were disproportionately represented in the sample (45%), although diagnoses of personality disorders (48%) rather than mood (17%) or psychotic (10%) disorders accounted for most of these cases. Nearly 75 percent of inmates who initiated hunger strikes did so while residing in disciplinary housing. In more than 80 percent of the strikes, the reason for stopping the strike was unknown. When the reasons were known, custody intervention rather than mental health intervention was the most common reason for the ending of a strike. Improving communication with custody administration and mitigating unnecessarily aversive housing environments are likely to reduce the incidence of hunger strikes.

Metabolic Syndrome Prevalence and Reduction in Inmates Prescribed Antipsychotic Medications.

The principal aim of this study was to establish whether a metabolic monitoring program implemented for second-generation antipsychotic medications (SGAs) was associated with any reduction in the prevalence of metabolic syndrome in adult inmates treated with antipsychotic medications in the New Jersey Department of Corrections. The average prevalence of metabolic syndrome in those prescribed SGAs decreased from 17.9% during the years before metabolic monitoring to 14.3% during the years of monitoring. The number of patients prescribed antipsychotic medication decreased a net 35% over 9 years of the study. We conclude that metabolic monitoring was one of the several administrative interventions over the study period that reduced the unnecessary exposure of inmates to the risks of antipsychotic medications.

Nonemergency Involuntary Antipsychotic Medication in Prison: Effects on Prison Inpatient Days and Disciplinary Charges.

We hypothesized that treating mentally ill inmates involuntarily with antipsychotic medication would reduce the number of prison inpatient days and the number of inmates who receive disciplinary charges. The subjects were 133 mentally ill inmates who were placed on the New Jersey Department of Corrections (NJ DOC) nonemergency involuntary medication protocol and received antipsychotic medication for at least one year. No difference was noted in an inmate's mean number of prison inpatient days in the year before versus the year during involuntary medication. Fewer inmates received serious disciplinary charges during the year of involuntary medication relative to the year before, when they were not medicated. In addition, there were decreases in mean instances and mean total number of charges during involuntary medication versus before. Neither an increased number of inpatient days nor depot medication accounted for the inmates who incurred no charges while receiving involuntary medication.

Decreased Mortality Rates of Inmates With Mental Illness After a Tobacco-Free Prison Policy.

OBJECTIVE: Negative health consequences of smoking have prompted many correctional facilities to become tobacco free, including the New Jersey Department of Corrections, and this study examined the results of implementing tobacco-free policies. METHODS: Mortality rates in the total population of inmates and in a subgroup with identified special mental health needs or mental illnesses (referred to in this article as persons with special needs) were measured from January 2005 through June 2014, a period during which tobacco use was significantly reduced and then eliminated. RESULTS: The total mortality rate of all causes of death combined was three times higher for persons with special needs in 2005 compared with those without special needs. The total annual mortality rate decreased by 13%, from 232 to 203 per 100,000 population between 2005 and 2013. The mortality rate for persons identified as having special needs decreased by 48%, from an average of 676 per 100,000 population over the eight-year period before the ban to 353 per 100,000 in the 18 months after the ban. Reduced mortality among persons with special needs between 2005 and 2014 in half-year increments was correlated with the reduction and elimination of tobacco products (median bootstrapped Pearson r=.60, 95% confidence interval [CI] =.21 to .86). In strong contrast, however, the bootstrapped correlation between the mortality rate of persons not identified as having special needs and tobacco sales over the same period was not significant (median Pearson r=-.13, CI=-.50 to .28). No other major medical intervention occurred during these years. CONCLUSIONS: This striking correlation of quick and substantial reduction of mortality among individuals with a mental illness in association with the reduction and subsequent ban of smoking suggests that smoking may play a major role in the reduced life span of persons with mental illness.

The prevalence of delusional disorder in prison.

Delusional disorder has important implications for forensic psychiatrists, as delusions are not infrequently related to criminal behavior. Thus, we hypothesized that delusional disorder is over-represented in correctional populations. We conducted a retrospective chart review of the electronic medical records from 2000 to 2012 of New Jersey Department of Corrections inmates who remained incarcerated as of March 2012. Potential cases of delusional disorder were initially identified by using a search for current or past diagnoses of such disorders or other diagnoses that could be misdiagnosed cases. After an initial chart review identified an inmate as having probable delusional disorder according to Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR) criteria, the diagnosis was confirmed by at least one concurring independent review. We estimate a point prevalence of 0.24 percent for delusional disorder in our population, which is eight times higher than that expected in the community.

Single cells, segregated housing, and suicide in the New Jersey Department of Corrections.

Single-cell and segregated housing are established risk factors for suicide in prison. The importance of these factors together may represent a disproportionate risk and are both modifiable. We tallied the housing locations and single- versus double-cell status of the 26 inmates who committed suicide in the New Jersey Department of Corrections (NJDOC) from 2005 through 2011, and compared the suicide rates in these housing arrangements. All single-cell housing in the NJDOC (whether segregated or general population) represented a higher risk of suicide than double-cell housing in the general population. Single-cell detention was the riskiest housing in the NJDOC, with a suicide rate that was more than 400 times the rate of suicide in double-cell general population housing and 23 times the rate of suicide in the prison system overall. The odds ratios of suicide in single-cell detention represent the highest reported in the literature in terms of risk factors for suicide in prisoners. Apprised of this risk, the NJDOC, assisted by its mental health vendor, University Correctional Health Care (UCHC, of Rutgers University, formerly the University of Medicine and Dentistry of New Jersey), adopted in 2012 a practice of default double-celling of inmates placed in detention.

Benefits of a department of corrections partnership with a health sciences university: New Jersey's experience.

More than half of the state prisons in the United States outsource health care. While most states contract with private companies, a small number of states have reached out to their health science universities to meet their needs for health care of prisoners. New Jersey is the most recent state to form such an agreement. This article discusses the benefits of such a model for New Jersey's Department of Corrections and for New Jersey's health sciences university, the Rutgers University, formerly the University of Medicine and Dentistry of New Jersey. The benefits for both institutions should encourage other states to participate in such affiliations.

Successful removal of quetiapine from a correctional formulary.

The abuse of medications in prison is a phenomenon well known among correctional health care professionals, and quetiapine has emerged as a drug of abuse in these settings. Considering the risks of abuse and diversion and the high cost compared with effective alternative antipsychotic medications, the New Jersey Department of Corrections (NJDOC) Pharmacy and Therapeutics Committee voted to remove quetiapine from the formulary. In a retrospective chart review, clinically relevant outcome measures were evaluated in patients prescribed quetiapine at the time of this change. Psychiatrists attempted to stop the quetiapine in 63.4 percent of the cases and were successful (not requiring continuation or restarting of the medicine) 95.7 percent of the time. There were no statistically significant differences in the number of patients who needed a higher level of care, days in a higher level of care, number of patients needing constant (e.g., suicide) watch, days on constant watch, suicidal behavior, or disciplinary charges when the subjects in whom an attempt to discontinue quetiapine was made was compared with those in whom it was continued. In 44.7 percent of cases in which an attempt was made to stop quetiapine (and in 28.3% of cases in the entire NJDOC population as of January 2009), no antipsychotic medication was needed to manage the patients during the study period. This study supports the decision to remove quetiapine from the NJDOC formulary.

Guideline, education, and peer comparison to reduce prescriptions of benzodiazepines and low-dose quetiapine in prison.

Benzodiazepines (antianxiety medications) and quetiapine (an antipsychotic medication) are subject to abuse in prison. Quetiapine is also expensive and has serious side effects. The prescription of these medications in prison for anxiety and insomnia is not the preferred choice. In order to reduce these prescriptions, the University of Medicine and Dentistry of New Jersey-University Correctional HealthCare (UCHC), working within the New Jersey Department of Corrections, provided its psychiatrists with a guideline to the treatment of insomnia in prison. The guideline discouraged pharmacological treatment of insomnia. UCHC then anonymously compared the prescribing practices of its psychiatrists to each other, and educated the psychiatrists about the disadvantages of benzodiazepines and low-dose quetiapine in prison. These techniques reduced the numbers of inmates prescribed benzodiazepines by 38% after 20 months and reduced the numbers of inmates prescribed low-dose quetiapine by 59% after 22 months.

Creation of a metabolic monitoring program for second-generation (atypical) antipsychotics.

Second-generation or ''atypical'' antipsychotics can cause metabolic derangements that lead to diabetes and cardiovascular disease. To potentially minimize these adverse effects, the University of Medicine and Dentistry of New Jersey - University Correctional HealthCare (UCHC) and the New Jersey Department of Corrections (NJ DOC) created a metabolic monitoring program that was incorporated into the electronic medical record. This program is used statewide by UCHC psychiatrists working within the NJ DOC.