Examining the Link Between Unintentional Overdose Death and Prior Criminal History in Illinois

Introduction

Drug overdose is one of the leading causes of unintentional death for persons in the United States.^[1] According to the Centers for Disease Control and Prevention,^[2] approximately two out of three of these deaths are related to opioids, including prescription opioids (e.g., oxycodone, morphine) and illicit opioids (e.g., fentanyl, heroin). The highly addictive nature of opioids may lead an individual to develop an opioid use disorder, which can precede disability and repeated relapse.^[3] Opioid use can lead to fatal or non-fatal overdose that includes side effects such as suppressed breathing and reduced heart rate.^[4] The COVID-19 pandemic has also exacerbated the opioid epidemic and led to increased drug overdose rates throughout the country.^[5]

There have been calls for research to understand opioid and other substance misuse and offer treatment and intervention recommendations, particularly for persons with criminal justice system involvement.^[6] As persons released from incarceration have especially high risk for overdose during the period immediately following release, there is urgent need for evidence-based response and aftercare.^[7]

This study examined fatal drug overdoses in Illinois. I linked Illinois unintentional fatal drug overdose data with two Illinois justice system data sources: arrest data and corrections data. This linkage made it possible to compare the characteristics of justice-involved and non-justice-involved drug overdose decedents. I also offer recommendations for prevention and intervention efforts.

Literature Review

The criminal justice system may exacerbate substance use disorders and potentially increase risk for overdose.^[8] Police officers frequently come into contact with persons misusing substances, and this can result in arrest and jail detention with limited referrals to treatment.^[9] In addition, individuals who have had prior substance-related police contact who witness overdose may be less likely to call for police or emergency services in fear of arrest.^[10] Although probation and court services may link individuals with treatment, medication-assisted treatment may be stopped in favor of abstinence, which can be dangerous.^[11]

In prisons, over half of persons incarcerated meet the criteria for a substance use disorder, but few receive screening or effective treatment.^[12] Although studies have suggested that cross-system care between health and justice systems should be enhanced, researchers have recognized that lack of funding can create a barrier to this level of care.^[13] Treating substance use in jails and prisons has shown positive outcomes and would reduce costs to the public over time, but experts have noted that correctional staff time and effort (i.e., in delivering medical treatment) may be a high burden for facilities to pay upfront.^[14]

The time period after release from prison is especially high risk for overdose. Decreased drug tolerance after a period of abstinence in prison can increase risk for overdose after release.^[15] Additional factors such as a lack of social support and accountability, mental health disorders, homelessness, and unstable finances may contribute to stress which can lead to relapse.^[16]

Throughout the criminal justice system, the use of, and distribution of, naloxone can reduce opioid fatalities.^[17] In Illinois, police officers and other first responders may carry naloxone. The administration of naloxone is a harm reduction strategy for addressing opioid use disorders with much research dedicated to studying its effectiveness.^[18] A review from Reichert and Gleicher (2017) noted that naloxone has played a significant role in reducing overdose deaths, with naloxone education and programming resulting in increased survival rates.^[19]

Overall, research has highlighted the relationship between justice involvement and overdose, especially for those who have been recently released from incarceration and those who encounter treatment barriers and lack of support.^[20] While some strides have been made by the justice system, collaborative and comprehensive responses are needed to address the growing number of persons who die by unintentional fatal overdose, particularly related to increases in opioid and psychostimulant usage.

Methodology

Three data sources were used in this project. Fatal opioid overdose data collected from July 2017 through December 2018 were available from the Illinois State Unintentional Drug Overdose Reporting Surveillance (SUDORS) system housed by Northwestern University. SUDORS data is obtained from death certificates and coroner/medical examiner reports submitted by participating Illinois counties.^[21] Arrest data from the Illinois State Police’s Criminal History Record Information (CHRI) and incarceration data from the Illinois Department of Corrections (IDOC) were linked with SUDORS data to assess relationships between criminal justice involvement and unintentional fatal overdose.

The original data included information on 2,833 persons who died of a fatal opioid-related overdose from July 2017 to December 2018. Identifiers were missing from 245 (8.6%) of these individuals, which made it impossible to determine if they had criminal histories. Thus, they were removed from the dataset, leaving 2,588 individuals. Four individuals were removed because their death date recorded in SUDORS preceded their last arrest recorded in CHRI, which may be because the arrests were attributed to the wrong individual (Figure 1).

In CHRI, an individual’s fingerprints are matched across all records in the system to generate their criminal history. If the digitized fingerprint data becomes corrupted, two individuals’ records can be erroneously linked. An upcoming internal audit of CHRI data may examine how and why this occurs.

Figure 1
Final Study Sample Sizes

Findings

SUDORS data showed Cook County accounted for over half (59.8%) of the recorded overdoses. Of all overdose decedents examined, the majority had a prior arrest (n = 2,136; 82.7%) and almost one-third (n = 819; 31.7%) had a prior incarceration on their records. Overall, overdose decedents were more likely to be male (74.0%), White (68.8%), and non-Latinx (82.0%), with a mean age of 42 years old. Decedents with criminal histories were more likely to be non-White (34.3%) than those without criminal history (18.5%). Table 1 provides a demographic breakdown of decedents by arrest history.

Table 1
Demographics of Overdose Decedents With and Without Prior Arrests (n = 2,584)

Note. Race may equal more than total sample, as individuals could be coded for more than one race. Age was unknown for one decedent.

Most individuals fatally overdosed in their homes, abandoned buildings, motels, and parking lots. Of the various modes through which drugs can be administered, decedents most commonly injected their fatal dose (24.8%). Bystanders were present at the scene of an overdose in almost one-third of the cases (28.8%). A bystander may be a critical element of assisting a person who has overdosed on opioids, as they can administer naloxone, an opioid reversal agent. While it is impossible to say whether these overdoses could have been prevented, the percentage of decedents with bystanders present at their fatal overdose may indicate a need for additional community training and resources in overdose rescue and naloxone administration.

Substance use treatment histories were similar among individuals with and without arrest histories. However, a higher proportion of persons who had not been arrested had a history of mental illness treatment than those who had been arrested (21.2% no arrest vs. 16.0% arrest) or were engaged in mental illness treatment at time of death (13.2% no arrest vs. 8.7% arrest). This does not necessarily mean that persons without arrest history were more likely to experience mental health problems, but perhaps these persons had fewer risk factors and external barriers that prevented them from receiving treatment in comparison to persons with criminal history.

The largest proportion of arrest charges that these individuals experienced were for property offenses (e.g., theft, fraud, criminal trespass; 26.8% of charges). Ordinance and traffic code violations primarily comprised the next largest category of arrest charges (e.g., drinking in public, soliciting unlawful business; 21.9% of charges), followed by drug-related offenses (e.g., possession of a controlled substance, possession of drug paraphernalia; 20.8% of charges). Although ordinance violations made up the second largest proportion of arrest charges, a higher proportion of individuals were actually convicted for drug-related offenses (29.0%) than for ordinance violations (7.6%).

Most overdose decedents with an arrest history had a lengthy involvement with the criminal justice system, with a median of 16 years between first and last arrest and seven years between first prison admit and last prison exit. Overdose decedents had a median of nine prior arrests. The time between an individual’s last contact with the system and death was relatively short—overdose decedents had only a median of 2 years between their last arrest and death (Figure 2). Of the 2,136 decedents with arrest history, 426 died within six months of their last arrest (19.9% of those with arrest history); 36 died within two weeks (1.7% of those with arrest history).

Figure 2
Times Between Arrest and Incarceration and Overdose Death (n = 2,584)

Note. Calculated from combined CHRI, IDPH, and IDOC datasets.

Of the 2,584 overdose decedents, 819 had a prison history. These individuals had 2,931 corrections admissions during their lifetimes, with a mean of 3.56 admits per person and median of 3.0 admits per person. A minimum of one admit and a maximum of 18 admits were recorded for each individual. Of those who went to prison, the majority were released to parole (89.2%). Overall, decedents with an incarceration history had a median of 3 years between their last prison exit and death. However, of the 819 persons with incarcerations, 167 died within six months of their release (20.4% of those with incarcerations) and 59 died within two weeks (7.9% of those with incarcerations).

Recommendations for Policy and Practice

Identify Opportunities for Justice System Intervention and Harm Reduction

Many overdose decedents in this sample experienced arrests and incarcerations prior to their fatal overdose (82.7% had arrest history and 38.3% of those with arrests experienced incarceration). There are several points in the criminal justice system which could serve as opportunities for intervention. Specifically, researchers have developed continuums of care targeted to individuals involved with the justice system which identify interception points to divert at-risk persons into treatment.^[22] Police, probation and court services, and correctional facilities offer openings where treatment can be considered. For those recently released from incarceration, proper reentry care and continued treatment are important for individuals with substance use disorders, especially for those with a coinciding mental health disorder. Follow-up should be conducted with these individuals to monitor known risks for overdose.

Further Research on Overdose and Criminal Justice Involvement

More research is needed to identify and evaluate cross-disciplinary interventions that are effective in preventing fatal overdoses within justice-involved persons using substances, particularly as new risk factors for overdose are identified. Larochelle et al. (2019) noted eight touchpoints which were associated with increased risk of fatal overdose:^[23]

1. High dosage of morphine-equivalents
2. Having a prescription for both an opioid and benzodiazepine
3. Having multiple opioid prescribers
4. Having multiple opioid-prescription-filling pharmacies
5. Having an inpatient withdrawal episode (i.e., opioid detoxification)
6. Experiencing a nonfatal opioid overdose
7. Having a potential injection-related infection requiring emergency care
8. Experiencing a release from incarceration

Intervention and prevention efforts that address these touchpoints and are considerate of age- and sex-related differences are needed. Future studies should also focus on learning how education and treatment can best be implemented and delivered to justice-involved persons.^[24]

Conclusion

Persons who died by unintentional overdose in Illinois in 2017 and 2018 commonly had criminal histories with multiple arrests and/or incarcerations throughout their lives. Further, the arrest charges leading up to their deaths were often drug-involved, which may have indicated risk for drug-related mortality. Many individuals died within two years post-incarceration, pointing to the need for more effective post-release substance misuse treatment strategies. In this sample, all overdose deaths were opioid-related, but persons who misuse opioids frequently use multiple substances, so prevention and treatment strategies must also account for polysubstance use.^[25] Research that continues to build upon our knowledge of overdose risks, particularly related to involvement with the justice system, will inform future prevention and intervention efforts. As participation in SUDORS continues to expand throughout the state, new studies may provide a more comprehensive look at Illinois drug overdoses.