The rate of drug overdose deaths has increased substantially over the past decade, but there are opportunities to address this growing concern. The risk of overdose death is particularly heightened when individuals with substance/opioid use disorder (SUD; OUD) encounter a transition in their lives, such as completing OUD treatment or being released from a correctional facility (e.g., prison or jail).

Factors contributing to increased risk during transitional periods:

• Lower drug tolerance after a period of non-use combined with difficulty judging tolerance in dosing, and
• Disruptions in treatment, social support (e.g., friends, community), financial wellbeing, and connections to resources that address root causes of OUD (e.g., mental health, housing).

Treatment Completion

Treatment for OUD could include medications for opioid use disorder (MOUD; e.g., buprenorphine, methadone), counseling, and/or residential and hospital-based treatment. The risk for overdose death is higher in the period directly after OUD treatment, including after detoxification and ceasing to take MOUD.

• The month after ending treatment is associated with significantly elevated risk (i.e., 5 times higher for ending treatment without medications; and 2 times higher after ending medication treatment compared to periods more than a month after ending treatment).^1,2
• The period directly after detoxification is a time of increased overdose risk. ^3,4
• The period directly after ending treatment with MOUD (including buprenorphine, methadone, etc.) also has an elevated risk of mortality. ^2,5
• Specific reasons for elevated risk after treatment vary, but loss of tolerance, meaning a return to using opioids at the level used prior to treatment, may contribute to overdose deaths.³

Release from Correctional Facilities

Similar to the risk following detoxification or MOUD cessation, the period after release from correctional facilities is a very high-risk period for overdose. Studies across multiple states show that the risk of overdose is extremely high (upwards of 8-40 times the standard risk) in the two weeks following release.^6-9

Elevated risk post-release could be due to various reasons, such as:

• Lack of treatment or interruptions in treatment. ^10,11
• Loss of, or changes in, tolerance (i.e., tolerance lowers while confined, so using pre-incarceration amounts may be more likely to lead to overdose).^11-13
• Disruptions to social and economic support.¹¹

Considerations for Policymakers to Reduce OD Risk during Transition Periods

• Increase access to harm reduction approaches. Harm reduction is effective for reducing risk of overdose death, as well as other potential harmful outcomes of drug use. There is a wide literature on the effectiveness of harm reduction, such as access to and use of naloxone, drug checking or fentanyl testing, access to MOUD, and needle exchange.¹⁴
• Enable and sustain access to MOUD in correctional facilities and across facility transfers. It is also important to ensure access to MOUD upon release through discharge planning.^15,16 Moreover, MOUD access in jail can be cost-effective¹⁷ and may reduce recidivism.
• Bolster the capacity of correctional facilities to connect individuals to community-based programs and services upon their release from incarceration. Access to these resources can support recovery and wellbeing.¹⁸ Efforts could focus on:
  • Increasing correctional facilities’ awareness of the resources available to the individuals they are releasing, and
  • Nurturing partnerships between these facilities and community-based programs – which could support community reintegration for individuals with and without OUD.

References

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2. Davoli M, Bargagli AM, Perucci CA, et al. Risk of fatal overdose during and after specialist drug treatment: the VEdeTTE study, a national multi-site prospective cohort study. Addiction. 2007;102(12):1954-1959.
3. Strang J, McCambridge J, Best D, et al. Loss of tolerance and overdose mortality after inpatient opiate detoxification: follow up study. BMJ (Clinical research ed). 2003;326(7396):959-960.
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