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. Author manuscript; available in PMC: 2023 Jan 1.
Published in final edited form as: Am J Prev Med. 2021 Sep 12;62(1):e29–e37. doi: 10.1016/j.amepre.2021.06.014

Legal System Involvement and Opioid-Related Overdose Mortality in VA Patients

Andrea K Finlay 1,2, Kristen M Palframan 3, Matthew Stimmel 4, John F McCarthy 3
PMCID: PMC8849578  NIHMSID: NIHMS1757314  PMID: 34521559

Abstract

Introduction:

Opioid-related overdose risks are elevated following incarceration. Rates of opioid-related overdose mortality have risen in recent years, including among Veterans Health Administration (VHA) patients. To inform Veteran overdose prevention, this study evaluated whether opioid-related overdose risks differ for Veteran VHA patients with versus without indicators of legal system involvement.

Methods:

This retrospective national cohort study, conducted in 2019–2021, used VHA electronic health records and death certificate data from the VA/Department of Defense Mortality Data Repository (MDR) to examine opioid-related overdose mortality from 1/1/2013 through 12/31/2017. The cohort included 5,390,902 Veterans with VHA inpatient or outpatient encounters in 2012 who were alive as of 1/1/2013, of whom 32,284 patients (0.60%) had legal system involvement in 2012, indicated by Veterans Justice Programs outpatient encounters. Cox proportional hazards regression models assessed associations between legal involvement and risk of opioid-related overdose mortality.

Results:

There were 4,670 opioid-related overdose deaths, including 295 (6.31%) among legal-involved Veterans. Veterans with legal involvement, compared to those without, had a higher opioid-related overdose mortality rate per 100,000 person-years (191.22, 95% confidence interval [CI]=169.40–213.04 vs. 17.76, 95% CI=17.23–18.29, p<0.001) and an elevated risk of opioid-related overdose mortality (adjusted hazard ratio=1.38, 95% CI=1.22–1.57, p<0.001).

Conclusions:

Among Veterans receiving VHA care in 2012, documented legal system involvement was associated with increased risk of opioid-related overdose mortality. Targeting overdose education and naloxone distribution programs and integrating opioid overdose prevention efforts into mental health care may reduce opioid overdose deaths among Veterans with legal involvement.

Keywords: Opioid-related disorders, Overdose, Mortality, Veterans, Criminal justice

Introduction

In 2018, more than 46,000 people in the United States (US) died of an overdose that involved opioids.1 Among people exiting prison or jail, risks of opioid overdose are 5 to 10 times greater than those of the general population.2–4 Military Veterans exiting prison have an increased risk of mortality, compared to other people exiting incarceration, and the leading cause of death is overdose.5 Incarceration may pose challenges for Veterans that increase vulnerability to opioid-related overdose, including decreased tolerance of opioids, poor continuity of care from correctional to community providers, and disrupted social networks and prison-related stigma.6,7. Other forms of legal system involvement, such probation or parole, may also be associated with increased risk for opioid overdose.8 Veterans with legal involvement have lower odds of receiving medications for opioid use disorder, which attenuate risk of overdose,9 than other Veterans.10,11 The Veterans Health Administration (VHA), which provides health care for Veterans, has developed the Opioid Safety Initiative, which is focused on improving the safety of opioid prescribing and includes a national program to deliver overdose education and distribute naloxone to Veterans.12,13 However, these programs only recently began targeted efforts to Veterans with legal system involvement.

Involvement in the criminal legal system is an opportunity to intervene with people who may be disconnected from healthcare.14 A review of medications for opioid use disorder programs delivered prior to, during, and after incarceration indicates that receipt of these medications reduces overdose mortality.15 The VHA intervenes with Veterans at various points in the legal system through the Veterans Justice Programs, which serve Veterans in prison through the Health Care for Reentry Veterans program and Veterans in jails, courts and law enforcement settings through the Veterans Justice Outreach program.16 Staff from these programs assess treatment needs and link Veterans to healthcare and other services (e.g., housing). Most legal-involved Veterans are diagnosed with a substance use disorder;17,18 thus, linkage to substance use disorder treatment services is a large part of the Veterans Justice Programs.

To ensure VHA policy and overdose prevention work is effective and that there is continuity and coordination among health care operations teams, it is important to understand baseline overdose mortality among legal-involved Veterans. The study hypothesis was that, among Veterans receiving VHA care, legal-involved Veterans would have elevated risk for opioid-related overdose mortality compared to Veterans without documented legal system involvement.

Methods

Design and Setting

Following the design of a prior study that found a higher risk of suicide attempts and death among Veterans in the Veterans Justice Programs compared to non-legal-involved Veterans,19 this retrospective cohort design used national VHA administrative records from the National Patient Care Database and Corporate Data Warehouse and mortality data from the Department of Veterans Affairs/Department of Defense Mortality Data Repository. VHA records contain all care provided by VHA, including Veterans Justice Programs data. The Mortality Data Repository contains comprehensive mortality data per annual searches of the Centers for Disease Control and Prevention’s National Death Index,20 which is the gold standard of US mortality databases. The National Death Index sensitivity ranges from 87–98%,21 was used by the VHA to develop a clinical decision support tool to estimate opioid overdose risk,22 and is the foundation for ongoing VHA suicide and overdose surveillance. VHA and mortality records were linked using Veteran social security numbers. This study was conducted as part of VHA Office of Mental Health and Suicide Prevention program evaluation activities.

Veterans Justice Programs

Veterans Justice Programs services are directed to Veterans with criminal legal system (e.g., property offenses, drug offenses), rather than the civil legal system (e.g., housing/eviction law, credit/debt collection), involvement. Veterans in legal settings are identified through several mechanisms, including asking people during the legal process if they served in the military, self-identification, and the Veterans Reentry Search Service, which matches correctional and court system records to Veterans records from the Department of Defense and the Department of Veterans Affairs.23–25 Veterans Justice Programs outreach staff are alerted to Veterans in the legal system through direct contact from Veterans or their family and friends, legal system contacts (e.g., attorneys), or lists generated via the Veterans Reentry Search Service.

Participants

The cohort included Veterans who received VHA inpatient or outpatient services in 2012 and were alive as of 1/1/2013. Veterans with a 2012 death record in the Mortality Data Repository were excluded.

Measures

Mortality.

The primary outcome was opioid-related overdose mortality, assessed in 2013 through 2017. Overdose cause of death was categorized using International Statistical Classification of Diseases and Related Health Problems 10th Revision (ICD-10) codes X40–44, X60–64, Y10–14, X85. Opioid-related overdoses were identified using ICD-10 multiple cause-of-death codes for opioids (T40.0, T40.1, T40.2, T40.3, T40.4, or T40.6).

Demographic and clinical characteristics.

Demographic and clinical characteristics of the cohort at baseline in 2012 were assessed. The focal predictor was receipt of at least one Veterans Justice Programs encounter in 2012,16 per program-specific outpatient clinic codes (591 for the Health Care for Reentry Veterans program and 592 for the Veterans Justice Outreach program). Demographic characteristics included age in years (categorized as 18–34, 35–54, 55–74, and 75–115), sex, race/ethnicity (white, black, Hispanic, other, and unknown), marital status (married, divorced/separated/widowed, never married/single, and unknown), region of the US (Northeast, Midwest, South, and West, per Census definitions), rurality (urban or rural, per Census-based Rural Urban Commuting Area codes), indications of homelessness (per ICD-9-CM diagnosis code V60.0, outpatient stop codes 501, 504, 507, 508, 511, 515, 522, 528, 529, 530, 555, 556, or 590, and inpatient bed section codes 28, 29, 37, or 39), and military service-connected disability status. Clinical characteristics included having an opioid prescription filled, diagnoses of mental health and substance use disorders, documentation of suicide attempts per diagnosis codes or provider reports, and receipt of medications for opioid use disorder (as defined by having an VHA opioid treatment program encounter or receipt of buprenorphine or naltrexone [inpatient or outpatient settings] or buprenorphine, naltrexone, or methadone [pharmacy records] within 12 months of an opioid use disorder diagnosis) in 2012.

Statistical Analyses

Descriptive statistics were generated, overall and by type of Veterans Justice Programs encounter received in 2012. Risk time for rates and proportional hazards models was calculated from 1/1/2013 until 12/31/2017 or death, whichever came first. Rates are presented per 100,000 person-years and were calculated as the number of deaths in 2013–2017 divided by the sum of risk time in the underlying population, in years, multiplied by 100,000. To test mortality rate differences between Veterans who did and did have a Veterans Justice Programs encounter (overall and separately for each program), the normal approximation was used based on National Vital Statistics methods.26

Unadjusted and adjusted Cox proportional hazards regression models were used to assess associations between receipt of a Veterans Justice Program encounter and risk of opioid-related overdose death. Five sensitivity analyses were completed: (1) risk for Veterans with a Health Care for Reentry Veterans encounter; (2) risk for Veterans with a Veterans Justice Outreach encounter; (3) risk for Veterans with a face-to-face VHA encounter within 2 years following their final Veterans Justice Programs encounter in 2012, to ensure incarcerated Veterans were not incarcerated the entire follow-up period and were able to access VHA care; (4) risk adjustment for receipt of medications for opioid use disorder in 2012; and (5) propensity score matching to account for differences between Veterans with and without legal involvement (described in detail in the Appendix). There were no missing data. All analyses were conducted using SAS version 9.4 software27 in 2019–2021.

Results

Descriptive statistics of demographic, clinical, and mortality characteristics are reported in Table 1, overall and stratified by type of Veterans Justice Programs encounters. There were 5,390,902 Veterans in the cohort and of these Veterans 32,284 (0.60%) had a Veterans Justice Programs encounter, including 6,914 (0.13%) with a Health Care for Reentry Veterans encounter and 25,988 (0.48%) with a Veterans Justice Outreach encounter. There were 4,670 opioid-related overdose deaths, including 295 (6.31%) among Veterans with Veterans Justice Programs contact.

Table 1.

Characteristics of Veterans at Veterans Health Administration Facilities, Stratified by Veterans Justice Programs

Characteristics Overall Any VJP contact Any HCRV contact Any VJO contact No VJP contact
N (%) N (%) N (%) N (%) N (%) p-value
Total N 5,390,902 (100) 32,284 (0.60) 6,914 (0.13) 25,988 (0.48) 5,358,618 (99.40)
Sex < 0.001
 Female 445,176 (8.26) 1,374 (4.26) 163 (2.36) 1,227 (4.72) 443,802 (8.28)
 Male 4,945,726 (91.74) 30,910 (95.74) 6,751 (97.64) 24,761 (95.28) 4,914,816 (91.72)
Age, m(SD) 61.74 (16.33) 47.85 (13.01) 51.69 (11.07) 46.86 (13.27) 61.82 (16.31) < 0.001
 18 to 34 471,521 (8.75) 7.039 (21.80) 655 (9.47) 6,481 (24.94) 464,482 (8.67)
 35 to 54 1,064,599 (19.75) 13,852 (42.91) 3,233 (46.76) 10,910 (41.98) 1,050,747 (19.61)
 55 to 74 2,637,571 (48.93) 11,040 (34.20) 2,922 (42.26) 8,343 (32.10) 2,626,531 (49.02)
 75 to 115 1,217,211 (22.58) 353 (1.09) 104 (1.50) 254 (0.98) 1,216,858 (22.71)
Race/Ethnicity < 0.001
 Black 803,864 (14.91) 8,908 (27.59) 2,269 (32.82) 6,820 (26,24) 794,956 (14.84)
 Hispanic 172,614 (3.20) 1,228 (3.80) 175 (2.53) 1,073 (4.13) 171,386 (3.20)
 Other 410,364 (7.61) 5,162 (15.99) 892 (12.90) 4,385 (16.87) 405,202 (7.56)
 White 3,832,103 (71.08) 15,875 (49.17) 3,266 (47.24) 12,900 (49.64) 3,816,228 (71.22)
 Unknown 171,957 (3.19) 1,111 (3.44) 312 (4.51) 810 (3.12) 170,846 (3.19)
Marital status < 0.001
 Married 2,963,416 (54.97) 6,239 (19.33) 1,045 (15.11) 5,295 (20.37) 2,957,177 (55.19)
 Divorced/ Separated/ Widowed 1,444,415 (26.79) 13,050 (40.42) 3,259 (47.14) 10,095 (38.84) 1,431,365 (26.71)
 Never married /Single 817,157 (15.16) 12,240 (37.91) 2,303 (33.31) 10.145 (39.04) 804,917 (15.02)
 Unknown 165,914 (3.08) 755 (2.34) 307 (4.44) 453 (1.74) 165,159 (3.08)
Region < 0.001
 Northeast 753,315 (13.97) 4,271 (13.23) 568 (8.22) 3,770 (14.51) 749,044 (13.98)
 Midwest 1,223,779 (22.70) 7,373 (22.84) 1,459 (21.10) 6,066 (23.34) 1,216,406 (22.70)
 South 2,307,717 (42.81) 13,512 (41.85) 4,119 (59.57) 9,684 (37.26) 2,294,205 (42.81)
 West 1,106,091 (20.52) 7,128 (22.08) 768 (11.11) 6,468 (24.89) 1,098,963 (20.51)
Rurality < 0.001
 Urban 3,588,788 (66.57) 25,460 (78.86) 5,093 (73.66) 20,871 (80.31) 3,563,328 (66.50)
 Rural 1,802,114 (33.43) 6,824 (21.14) 1,821 (26.34) 5,117 (19.69) 1,795,290 (33.50)
Homelessness 205,284 (3.81) 16,505 (51.12) 3,193 (46.18) 13,748 (52.90) 188,779 (3.52) < 0.001
Service-connected disability 2,309,227 (42.84) 13,701 (42.44) 1,839 (26.60) 12,101 (46.56) 2,295,526 (42.84) 0.15
Opioid prescription filled in 2012 1,321,776 (24.52) 10,037 (31.09) 1,174 (16.98) 9,065 (34.88) 1,311,739 (24.48 < 0.001
Mental health diagnoses in 2012
Any mental health or SUD diagnosis 2,289,865 (42.48) 25,462 (78.87) 3,713 (53.70) 22,269 (85.69) 2,264,403 (42.26) < 0.001
 Alcohol use disorder 384,555 (7.13) 14,831 (45.94) 1,616 (23.37) 13,539 (52.10) 369,724 (6.90) < 0.001
 Opioid use disorder 53,359 (0.99) 3,535 (10.95) 417 (6.03) 3,210 (12.35) 49,824 (0.93) < 0.001
 Other substance use disorder 217,981 (4.04) 13,725 (42.51) 1,808 (26.15) 12,272 (47.22) 204,256 (3.81) < 0.001
 Anxiety 470,997 (8.74) 6,981 (21.62) 681 (9.85) 6,455 (24.84) 464,016 (8.66) < 0.001
 Bipolar disorder 125,950 (2.34) 3,716 (11.51) 396 (5.73) 3,404 (13.10) 122,234 (2.28) < 0.001
 Depression 1,032,152 (19.15) 14,895 (46.14) 1,632 (23.60) 13,558 (52.17) 1,017,257 (18.98) < 0.001
 PTSD 639,693 (11.87) 9,823 (30.43) 806 (11.66) 9,191 (35.37) 629,870 (11.75) < 0.001
 Schizophrenia 85,514 (1.59) 2,008 (6.22) 214 (3.10) 1.824 (7.02) 83,506 (1.56) < 0.001
Any indication of suicide attempt in 2012 15,634 (0.29) 1,100 (3.41) 82 (1.19) 1,040 (4.00) 14,534 (0.27) < 0.001
Received medication for opioid use disorder in 2012 16,927 (0.31) 1,091 (3.38) 76 (1.10) 1,031 (3.97) 15,836 (0.30) < 0.001
Received face-to-face VHA encounter within 2 years after final VJP encounter in 2012 - 28,909 (89.55) 5,389 (77.94) 24,103 (92.75) - -
Died by opioid-related overdose, 2013–2017 4,670 (0.09) 295 (0.91) 54 (0.78) 247 (0.95) 4,375 (0.08) < 0.001
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HCRV, Health Care for Reentry Veterans; PTSD, post-traumatic stress disorder; SD, standard deviation; SUD, substance use disorder; VHA, Veterans Health Administration; VJO, Veterans Justice Outreach; VJP, Veterans Justice Programs.

Compared to Veterans with no Veterans Justice Programs contact, Veterans with Veterans Justice Programs contact were more likely to be male, 18 to 54 years old, unmarried, and living in urban areas (Table 1). Veterans who were of Black or Other races were overrepresented among those with legal involvement. Over half (51.12%) of Veterans with criminal legal involvement had experienced homelessness or received homeless services, compared to 3.52% of Veterans without legal involvement. Mental health and substance use disorder diagnoses were more prevalent among Veterans with legal involvement (78.87%) than those without (42.26%). Opioid use disorder was higher among Veterans with legal involvement (10.95%) compared to those without (0.93%).

Veterans with Veterans Justice Programs contact were more likely to die from an opioid-related overdose than Veterans without Veterans Justice Programs contact (0.91% vs. 0.08%) in 2013 to 2017 (Table 1). The opioid-related overdose mortality rate per 100,000 person-years was 191.22 (95% confidence interval [CI] = 169.40–213.04) among Veterans with legal involvement, compared to 17.76 (95% CI = 17.23–18.29, p<0.001) among Veterans in VHA care without legal involvement. Opioid-related overdose mortality was elevated for Veterans with Health Care for Reentry Veterans (163.30 per 100,000 person years; 95% CI = 122.68–213.08, p<0.001) or Veterans Justice Outreach (199.00, 95% CI = 174.18–223.82, p<0.001) contact compared to Veterans with no legal involvement.

Having any encounter with the Veterans Justice Programs was associated with elevated risk of opioid-related overdose mortality in unadjusted (hazard ratio [HR]=10.75, 95% CI=9.55–12.09, p<0.001) and adjusted (HR=1.38, 95% CI=1.22–1.57, p<0.001) analyses (Table 2). Sensitivity analyses indicated an elevated risk of opioid-related overdose for Veterans with Health Care for Reentry Veterans contact (unadjusted HR=8.74, 95% CI=6.68–11.43, p<0.001; adjusted HR=2.40, 95% CI=1.83–3.14, p<0.001), Veterans with Veterans Justice Outreach contact (unadjusted HR=11.07, 95% CI=9.74–12.58, p<0.001; adjusted HR=1.23, 95% CI=1.07–1.41, p=0.003), and Veterans who used VHA face-to-face care within two years after their Veterans Justice Programs encounter (unadjusted HR=11.47, 95% CI=10.17–12.94, p<0.001; adjusted HR=1.34, 95% CI=1.18–1.52, p<0.001; Table 3). In addition, when the Cox proportional hazards model was adjusted for receipt of medications for opioid use disorder, the association between any encounter with the Veterans Justice Programs and opioid-related overdose mortality remained significant (adjusted HR=1.38, 95% CI=1.22–1.57, p<0.001). Among the propensity score matched cohort of 64,568 Veteran VHA users, having any encounter with the Veterans Justice Programs was positively associated with opioid-related overdose mortality (unadjusted HR=1.51, 95% CI=1.26–1.81, p<0.001; adjusted HR=1.38, 95% CI=1.15–1.66, p=0.001; Appendix).

Table 2.

Hazard Ratios for Opioid-Related Overdose Mortality Among Veterans at the Veterans Health Administration

Characteristics Opioid-Related Overdose Mortality
Hazard ratio 95% confidence interval p-value
Encounter with VJP in 2012
 Unadjusted 10.75 9.55–12.09 < 0.001
 Adjusted 1.38 1.22–1.57 < 0.001
Male (ref = Female) 1.59 1.42–1.78 < 0.001
Age group (ref = 18–34)
 35–54 0.82 0.75–0.89 < 0.001
 55–74 0.47 0.43–0.51 < 0.001
 75–115 0.07 0.05–0.09 < 0.001
Race/ethnicity (ref = white)
 Black 0.54 0.49–0.59 < 0.001
 Hispanic 0.81 0.69–0.96 0.01
 Other 0.91 0.83–0.99 0.02
 Unknown 0.85 0.70–1.03 0.09
Marital status (ref = Married)
 Divorced/separated/ widowed 2.23 2.06–2.41 < 0.001
 Never married/single 2.23 2.05–2.42 < 0.001
 Unknown 1.37 1.07–1.75 0.01
Region (ref = Northeast)
 Midwest 0.79 0.73–0.87 < 0.001
 South 0.66 0.60–0.71 < 0.001
 West 0.64 0.58–0.70 < 0.001
Rural (ref = urban) 0.70 0.65–0.75 < 0.001
Homelessness (ref = housed) 1.31 1.20–1.42 < 0.001
Any service connection (ref = none) 0.86 0.81–0.92 < 0.001
Opioid prescription filled in 2012 (ref = no) 2.51 2.36–2.67 < 0.001
Mental health diagnoses in 2012 (ref = no)
 Alcohol use disorder 1.21 1.12–1.31 < 0.001
 Opioid use disorder 5.74 5.28–6.25 < 0.001
 Other substance use disorder 2.51 2.30–2.75 < 0.001
 Anxiety 1.29 1.21–1.39 < 0.001
 Bipolar disorder 1.35 1.23–1.48 < 0.001
 Depression 1.43 1.34–1.53 < 0.001
 PTSD 1.07 1.00–1.15 0.07
 Schizophrenia 0.94 0.81–1.09 0.43
Any indication of suicide attempt in 2012 (ref = none) 1.14 0.97–1.33 0.11
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Note: Boldface indicates statistical significance (p<0.05). PTSD, post-traumatic stress disorder; VJP, Veterans Justice Programs.

Table 3.

Sensitivity Analyses of Opioid-Related Overdose Mortality Among Veterans at the Veterans Health Administration

Characteristics Opioid-Related Overdose Mortality
HCRV contact VJO contact VHA Face-to-Face
Encounter		 Receipt of MOUD
Unadjusted analyses HR 95% CI p-value HR 95% CI p-value HR 95% CI p-value HR 95% CI p-value
Encounter with HCRV 8.74 6.68–11.43 < 0.001
Encounter with VJO 11.07 9.74–12.58 < 0.001
Encounter with VJP 11.47 10.17–12.94 < 0.001
Adjusted analyses
Encounter with HCRV 2.40 1.83–3.14 < 0.001
Encounter with VJO 1.23 1.07–1.41 0.003
Encounter with VJP 1.34 1.18–1.52 < 0.001 1.38 1.22–1.57 < 0.001
Male (ref = Female) 1.60 1.43–1.78 < 0.001 1.60 1.43–1.78 < 0.001 1.60 1.43–1.78 < 0.001 1.59 1.42–1.77 < 0.001
Age group (ref = 18–34)
 35–54 0.81 0.75–0.88 < 0.001 0.82 0.75–0.89 < 0.001 0.82 0.75–0.89 < 0.001 0.83 0.76–0.90 < 0.001
 55–74 0.46 0.42–0.50 < 0.001 0.46 0.43–0.51 < 0.001 0.47 0.43–0.51 < 0.001 0.47 0.43–0.53 < 0.001
 75–115 0.07 0.05–0.09 < 0.001 0.07 0.05–0.09 < 0.001 0.07 0.05–0.09 < 0.001 0.07 0.05–0.09 < 0.001
Race/ethnicity (ref = white)
 Black 0.53 0.49–0.59 < 0.001 0.54 0.49–0.59 < 0.001 0.54 0.49–0.59 < .0001 0.54 0.49–0.59 < 0.001
 Hispanic 0.82 0.69–0.96 0.01 0.81 0.69–0.96 0.01 0.82 0.69–0.96 0.02 0.82 0.69–0.96 0.01
 Other 0.91 0.83–0.99 0.03 0.91 0.83–0.99 0.03 0.91 0.83–0.99 0.03 0.91 0.83–0.99 0.02
 Unknown 0.85 0.70–1.03 0.09 0.85 0.70–1.03 0.09 0.85 0.70–1.03 0.10 0.85 0.70–1.03 0.10
Marital status (ref = Married)
 Divorced/separated/widowed 2.23 2.06–2.41 < 0.001 2.23 2.07–2.41 < 0.001 2.22 2.06–2.40 < .0001 2.23 2.07–2.41 < 0.001
 Never married/single 2.23 2.05–2.42 < 0.001 2.23 2.05–2.42 < 0.001 2.23 2.05–2.42 < .0001 2.23 2.05–2.42 < 0.001
 Unknown 1.37 1.07–1.75 0.01 1.37 1.07–1.75 0.01 1.34 1.05–1.72 0.02 1.38 1.08–1.76 0.01
Region (ref = Northeast)
 Midwest 0.79 0.72–0.86 < 0.001 0.79 0.73–0.87 < 0.001 0.79 0.73–0.87 < .0001 0.80 0.73–0.87 < 0.001
 South 0.65 0.60–0.71 < 0.001 0.66 0.61–0.71 < 0.001 0.65 0.60–0.71 < .0001 0.66 0.61–0.72 < 0.001
 West 0.64 0.58–0.70 < 0.001 0.64 0.58–0.70 < 0.001 0.64 0.58–0.70 < .0001 0.64 0.58–0.70 < 0.001
Rural (ref = urban) 0.70 0.66–0.75 < 0.001 0.70 0.65–0.75 < 0.001 0.70 0.66–0.76 < .0001 0.70 0.66–0.76 < 0.001
Homelessness (ref = housed) 1.33 1.23–1.44 < 0.001 1.33 1.22–1.44 < 0.001 1.31 1.20–1.42 < .0001 1.30 1.20–1.42 < 0.001
Any service connection (ref = none) 0.87 0.81–0.92 < 0.001 0.86 0.81–0.92 < 0.001 0.87 0.81–0.92 < .0001 0.86 0.81–0.92 < 0.001
Opioid prescription filled in 2012 (ref = no) 2.51 2.36–2.67 < 0.001 2.51 2.36–2.67 < 0.001 2.52 2.37–2.68 < .0001 2.53 2.38–2.69 < 0.001
Mental health diagnoses in 2012 (ref = no)
 Alcohol use disorder 1.22 1.13–1.32 < 0.001 1.21 1.12–1.31 < 0.001 1.21 1.12–1.31 < 0.001 1.21 1.12–1.31 < 0.001
 Opioid use disorder 5.77 5.31–6.28 < 0.001 5.76 5.29–6.27 < 0.001 5.75 5.29–6.26 < .0001 5.37 4.89–5.89 < 0.001
 Other substance use disorder 2.53 2.31–2.76 < 0.001 2.52 2.31–2.76 < 0.001 2.52 2.30–2.75 < .0001 2.50 2.28–2.73 < 0.001
 Anxiety 1.30 1.21–1.39 < 0.001 1.29 1.21–1.39 < 0.001 1.30 1.21–1.39 < .0001 1.29 1.20–1.39 < 0.001
 Bipolar disorder 1.35 1.23–1.48 < 0.001 1.35 1.23–1.48 < 0.001 1.35 1.23–1.48 < .0001 1.35 1.23–1.48 < 0.001
 Depression 1.43 1.34–1.53 < 0.001 1.43 1.33–1.53 < 0.001 1.43 1.34–1.54 < .0001 1.43 1.34–1.53 < 0.001
 PTSD 1.08 1.00–1.16 0.047 1.07 1.00–1.15 0.07 1.07 1.00–1.15 0.07 1.07 1.00–1.15 0.07
 Schizophrenia 0.94 0.81–1.10 0.44 0.94 0.81–1.09 0.43 0.94 0.81–1.09 0.43 0.95 0.82–1.10 0.51
Any indication of suicide attempt in 2012 (ref = none) 1.15 0.98–1.34 0.09 1.14 0.98–1.34 0.11 1.14 0.97–1.34 0.11 1.14 0.97–1.34 0.11
Receipt of MOUD 1.24 1.10–1.39 < 0.001
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Note: Boldface indicates statistical significance (p<0.05). CI, confidence interval; HCRV, Health Care for Reentry Veterans; MOUD, Medications for opioid use disorder; PTSD, post-traumatic stress disorder; VJO, Veterans Justice Outreach; VJP, Veterans Justice Programs.

Discussion

Among more than 5 million Veterans who received services at VHA facilities in 2012, opioid-related overdose deaths occurred at a significantly higher rate of 191.22 per 100,000 person-years among Veterans with legal involvement and 17.76 per 100,000 person-years among Veterans without known legal involvement. The risk of overdose death among Veterans with legal involvement remained elevated in multivariable proportional hazards models even after adjusting for demographic and clinical factors. Sensitivity analyses were congruent with the primary findings and indicated that contact with either of the Veterans Justice Programs was associated with a high risk of opioid-related overdose mortality and results did not appreciably change when the sample was restricted to Veterans who received face-to-face VHA care within two years after their legal involvement or with the addition of receipt of medications for opioid use disorder. A propensity score-matched cohort also indicated that legal involvement is associated with a higher risk of opioid-related overdose mortality.

Elevated opioid-related overdose mortality among Veterans with legal involvement is consistent with other studies of incarcerated populations2,3 and highlights that a variety of criminal legal involvement, as indicated by Veterans Justice Programs contact, is associated with opioid overdose risk. Naloxone has been shown to reduce opioid overdose death rates for people leaving prison28 and there are numerous intercept points in the legal system that provide opportunities to screen for opioid overdose risk, deliver treatment, and provide overdose education and naloxone distribution.29 A jail-city partnership in San Francisco, California, serves as a model for how to conduct overdose education and naloxone distribution with incarcerated populations30 and a similar program for Veterans is in development in Cincinnati, Ohio State.31 Veterans on probation or parole would also benefit from overdose prevention education and naloxone distribution as studies have demonstrated that in legal-involved samples more than a quarter of overdose deaths occur among people on probation8 and only half have heard of naloxone, despite more than two-thirds experiencing or witnessing an overdose.32 Opioid-related overdose deaths continue to increase among Veterans,33 underscoring the urgency of expanding naloxone access and use, especially for Veterans with legal involvement.

Despite reviews indicating that medications for opioid use disorder reduce risk for overdose in general population samples34–36 and a growing body of evidence that these medications improve treatment engagement37,38 and reduce overdose risk among legal-involved populations,39–41 the risk for opioid-related overdose was not attenuated in this study when receipt of these medications was added to the model. These unexpected results may be because Veterans who use VHA care tend to differ from the general population42 or that the timing and pattern of medication use differs more for this sample than prior studies. Discontinuation of medication is associated with higher opioid overdose mortality.43 Furthermore, some legal-involved patients report plans to return to drug use or to use buprenorphine to periodically manage symptoms rather than for long-term treatment. 44 During fiscal year 2012 (the same year as data from this study), legal-involved Veterans had lower odds of receiving medications for opioid use disorder compared to non-legal-involved Veterans.11 It is possible that the risk of overdose was not attenuated by medication receipt because the legal-involved Veterans most in need of these medications did not receive them. A nuanced examination of medications for opioid use disorder utilization was beyond the scope of this study but should be examined in future research.

In addition to legal involvement, these findings suggest other areas for targeted programming focused on opioid overdose prevention. Veterans who received an opioid prescription had higher risk of an opioid-related overdose death and the VHA Opioid Safety Initiative is focused on reducing high dose opioid prescribing.12 However, Veterans with a substance use disorder or mental health disorder also had a higher risk of overdose death. Co-prescribing of opioids and benzodiazepines may partially explain this elevated risk.45 Other studies of legal-involved populations have also found a link between mental health diagnoses and overdose death,4,46,47 suggesting that substance use disorder treatment and overdose prevention efforts should be integrated into mental health treatment settings. The transition from incarceration to the community is marked by instability and stress.14 Additional support services for Veterans with mental health conditions may be needed. Homelessness was also associated with higher overdose mortality risk, indicating that housing support services may be especially critical after legal involvement. However, Veterans leaving incarceration do not meet the definition of homelessness after an incarceration of 90 days or greater and do not qualify for housing support services, even if they have no shelter upon release.48 This policy gap is especially troubling because the first few weeks after leaving incarceration are the highest risk period for overdose death.2,3 Finally, Veterans of Black or Other races were overrepresented among those with legal involvement and had a lower risk for overdose death. More detailed examination of these Veteran populations and possible interaction effects between race/ethnicity and legal involvement is needed.

Limitations

Study strengths included a national cohort of Veterans enrolled in VHA care, VHA administrative data collected by clinical staff, and use of National Death Index search results. However, there were limitations. Veterans with legal involvement may have been under-identified, as only those VHA patients with Veterans Justice Programs encounters were coded as having legal involvement. It is unknown what proportion of legal-involved Veterans receive outreach services or whether outreach varies by type of legal involvement, but not all Veterans in the legal system receive outreach services, either because they are not identified or because they are released from the legal setting before receiving outreach. Exact type of legal involvement, such as parole or arrests, could not be determined nor could it be determined whether Veterans were incarcerated or if released from incarceration when they left prison or jail. There may have been Veterans who died from opioid overdose between the time of their Veterans Justice Programs encounter and the start of 2013, as prior studies have shown that mortality risk is highest in the first few weeks after release from prison,2,3,49 but these Veterans would not have been included in the cohort. Also, some death may be uncaptured as the assessment was specific to death certificate data from the 50 US and the District of Columbia. Therefore, study findings may underestimate risks. Future research may help distinguish different mortality risk profiles by specific legal involvement as well as timing of legal involvement. Information on substance use disorder or opioid-specific treatment or programs Veterans may have received outside of VHA care that may impact overdose mortality were not available in VHA record. However, studies with Veterans and adults in the US indicate that most do not use substance use disorder or opioid-specific treatment,50,51 suggesting that the risk of bias is somewhat attenuated. It was not possible to include the impact of a Veteran having a personal supply of naloxone because the national VHA naloxone distribution program did not start until 2014. Naloxone records prior to this date are unreliable. Finally, these results may not generalize to Veterans who do not use VHA care. Veterans who use VHA care tend to be older and have more chronic medical and mental health problems than Veterans outside the system.52 However, results may be generalizable to some populations, including men who use Medicare or private insurance.42

Conclusions

Risk of opioid-related overdose death was elevated for Veterans with any type of criminal legal system involvement and was not attenuated by receipt of medications for opioid use disorder. Continuing to integrate opioid overdose education and naloxone distribution into the Veterans Justice Programs, identifying and addressing disparities in medication for opioid use disorder access, and enhancing clinical coordination between mental health and substance use disorder treatment services at the VHA will be key to reducing opioid-related overdose death among Veterans with legal involvement.

Supplementary Material

1

Acknowledgements

The authors have no conflicts of interests to disclose. No financial disclosures were reported by authors of this paper. This work was conducted as part of ongoing surveillance in the Office of Mental Health and Suicide Prevention, U.S. Department of Veterans Affairs. The views expressed in this article are those of the authors and do not necessarily reflect the position nor policy of the Department of Veterans Affairs (VA) or the United States government.

Footnotes

Financial disclosure: No financial disclosures were reported by authors of this paper.

Conflict of interest: The authors have no conflicts of interests to disclose.

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