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Twice a year, Oslo University Hospital awards a prize to just six outstanding research articles with key authors from the hospital. In December, the PriSUD project had the pleasure of receiving this award for the article "The association of prison security level with mortality after release from prison: a retrospective national cohort study (2000–16)"where we find high mortality after release among those who have been incarcerated in a high security prison. The article was written by Anne Bukten, Ingeborg Skjærvø and Marianne R. Stavseth. The prize was NOK 50 000, intended to fund further research.

Bukten, Anne; Skjærvø, Ingeborg; Stavseth, Marianne Riksheim. The association of prison security level with mortality after release from prison: a retrospective national cohort study (2000–16). The Lancet Public Health, Volume 7, Issue 7, 2022, Pages e583-e592, ISSN 2468-2667, https://doi.org/10.1016/S2468-2667(22)00107-4. Background Incarceration might contribute to increased mortality in an already marginalised population. A better understanding of the prison-related factors that are associated with mortality is important for preventing the negative health consequences of incarceration. We aimed to investigate all-cause and cause-specific mortality following release from high-security and low-security prisons. Methods In this retrospective national cohort study, we used data from the Norwegian Prison Release study (nPRIS), which includes complete national register data for 96 859 individuals from the Norwegian Prison Register linked to the Norwegian Cause of Death Register from Jan 1, 2000, to Dec 31, 2016. The study cohort included all people in Norway released from a high-security or low-security prison unit. Cause of death was categorised into internal causes (infectious, cancerous, endocrine, circulatory, respiratory, digestive, nervous system diseases, and mental health disorders) and external causes (accidents, suicides, and homicides) according to the 10th revision of the International Classification of Diseases. We calculated crude mortality rates (CMR) and estimated Cox proportional-hazards models. Findings There were 151 790 releases in the study period (68·4% from low-security and 31·6% from high-security prisons) from 91 963 individuals. The overall CMR was 854·4 [95% CI 834·7–874·2] per 100 000 person-years (436·2 [422·1–450·3] per 100 000 person-years for internal causes and 358·3 [345·5–371·1] per 100 000 person-years for external causes). The overall post-release mortality rate was higher in those released from high-security prisons (1142·5 [95% CI 1102·6–1182·5] per 100 000 person-years) than in those released from low-security prisons (714·6 [692·6–736·6] per 100 000 person-years). Our results suggest an association between release from high-security prisons and elevated mortality due to both external causes (adjusted hazard ratio [aHR] 1·75 [95% CI 1·60–1·91]) and internal causes (1·45 [1·33–1·59]), compared to release from low-security prisons. Interpretation Imprisonment and the post-release period can be an important point for public health interventions. Particular attention to health is warranted for individuals incarcerated in and released from high-security prisons. The potential impact of both individual-level characteristics of people incarcerated in high-security facilities, and of the prison environment itself, on mortality outcomes, should be investigated further.

The PriSUD project is a large research project that aims to improve health among inmates with substance use disorders. But how do you do that, and why is it so important? In order to explain this complex project in a simple way, we got the Danish research dissemination company madeclear to create a so-called 'explainer'; a film that shows what the PriSUD project is all about. Watch it here! made by madeclear.dk

Suvi Virtanen has been awarded a postdoctoral fellowship of 2,4 million SEK by the Swedish Research Council for Health, Working Life and Welfare (Forte). In her project “Evaluating effectiveness of substance misuse and addiction treatment in correctional services in Sweden” she will combine the use of nationwide register data with quasi-experimental methods to evaluate whether currently offered substance abuse treatments are effective in reducing recidivism, overdoses, and mortality. One of the project aims is to investigate the effectiveness of “contract treatment” (kontraktsvård), which is offered as an alternative sanction to prison for individuals whose committed crime was closely linked with substance misuse problems.

Hilde Pape, Philipp Lobmaier, Anne Bukten. An evaluation of eight short versions of the Drug Use Disorder Identification Test (DUDIT). A prison population study. Drug and Alcohol Dependence Reports, Volume 3, 2022. https://doi.org/10.1016/j.dadr.2022.100043 Background The eleven-item Drug Use Disorder Identification Test (DUDIT) is a recommended screening tool, but its length may impede its use in prison intake assessments. Hence, we examined the performance of eight brief DUDIT screeners against the full DUDIT, employing a sample of male inmates. Methods Our study included male participants in the Norwegian Offender Mental Health and Addiction (NorMA) study who reported pre-prison drug use and who had been incarcerated three months or less (n = 251). We performed receiver operating characteristic curve (ROC) analyses and estimated the area under the curve (AUROC) to assess the performance of DUDIT-C (four drug consumption items) and five-item versions that consisted of DUDIT-C and one additional item. Results Almost all (95%) screened positive on the full DUDIT (scores ≥6) and 35% had scores that were indicative of drug dependence (scores ≥25). The DUDIT-C performed very well in detecting likely dependence (AUROC=0.950), but some of the five-item versions performed significantly better. Of these, the DUDIT-C + item 5 (craving) had the highest AUROC (0.097). A cut-point of ≥9 on the DUDIT-C and ≥11 on the DUDIT-C + item 5 identified virtually all (98% and 97%, respectively) cases of likely dependence, with a specificity of 73% and 83%, respectively. At these cut-points, the occurrence of false positives was modest (15% and 10%, respectively) and only 4–5% were false negatives. Conclusions The DUDIT-C was highly effective in detecting likely drug dependence (according to the full DUDIT), but some combinations of DUDIT-C and one additional item performed better.

In collaboration with the entire PriSUD project group, we have published the protocol of the PriSUD project. In the paper, you can read about what the PriSUD project is, what our ambitions are in the years to come, and why it is so important. The article is open access and can be read and downloaded for free here

Bukten A, Lokdam NT, Skjærvø I, Ugelvik T, Skurtveit S, Gabrhelík R, Skardhamar T, Lund IO, Havnes IA, Rognli EB, Chang Z, Fazel S, Friestad C, Hesse M, Lothe J, Ploeg G, Dirkzwager AJE, Clausen T, Tjagvad C, Stavseth MR. PriSUD-Nordic—Diagnosing and Treating Substance Use Disorders in the Prison Population: Protocol for a Mixed Methods Study. JMIR Res Protoc 2022;11(3):e35182. doi: 10.2196/35182 Background: A large proportion of the prison population experiences substance use disorders (SUDs), which are associated with poor physical and mental health, social marginalization, and economic disadvantage. Despite the global situation characterized by the incarceration of large numbers of people with SUD and the health problems associated with SUD, people in prison are underrepresented in public health research. Objective: The overall objective of the PriSUD (Diagnosing and Treating Substance Use Disorders in Prison)-Nordic project is to develop new knowledge that will contribute to better mental and physical health, improved quality of life, and better life expectancies among people with SUD in prison. Methods: PriSUD-Nordic is based on a multidisciplinary mixed method approach, including the methodological perspectives of both quantitative and qualitative methods. The qualitative part includes ethnographic fieldwork and semistructured interviews. The quantitative part is a registry-based cohort study including national registry data from Norway, Denmark, and Sweden. The national prison cohorts will comprise approximately 500,000 individuals and include all people imprisoned in Norway, Sweden, and Demark during the period from 2000 to 2019. The project will investigate the prison population during three different time periods: before imprisonment, during imprisonment, and after release. Results: PriSUD-Nordic was funded by The Research Council of Norway in December 2019, and funding started in 2020. Data collection is ongoing and will be completed in the first quarter of 2022. Data will be analyzed in spring 2022 and the results will be disseminated in 2022-2023. The PriSUD-Nordic project has formal ethical approval related to all work packages. Conclusions: PriSUD-Nordic will be the first research project to investigate the epidemiology and the lived experiences of people with SUD in the Nordic prison population. Successful research in this field will have the potential to identify significant areas of benefit and will have important implications for ongoing policy related to interventions for SUD in the prison population.

Rose Boyle, PhD-student in the PriSUD-project, has published a new paper: «Operating between recovery and desistance: Researching substance use treatment in Norwegian prisons». This short article, published in the Nordic Journal of Criminal Science's special issue, discusses drug treatment methods in Norwegian prisons in the context of the ongoing debate on the criminalization and punishment of drug offenses, and trends toward harm reduction in Nordic drug policy. Many countries have moved in the direction of harm reduction and questions are being asked about the effects of criminalization and punishment of people with substance abuse disorders and the so-called "zero tolerance" drug policy. Norway has historically had a tendency towards strict drug legislation, as well as a high incidence of drug disorders and overdose deaths among both the prison population and recent releases, and this is discussed as part of the ongoing debate about the possible consequences of a drug reform. The article discusses methods for drug treatment in Norwegian prisons and the implications of these for both rehabilitation from drug disorders and distance from crime, seen in the light of the larger discourse on drug use, attitudes in society, criminal policy, and public health. The article is published in a special issue of the criminological journal 'Nordisk Tidsskrift for Kriminalvitenskab' and can be read here.

Pape, Hilde, Rossow, Ingeborg, and Bukten, Anne. "Are Short Audit Screeners Effective in Identifying Unhealthy Drinking of Varying Severity? A Prison Population Study." Drug and Alcohol Dependence 229, B (2021). https://doi.org/10.1016/j.drugalcdep.2021.109153. Background Whether brief versions of the Alcohol Use Disorder Identification Test (AUDIT) can be used as graded severity measures is largely unknown. We examined the performance of eight such brief screeners in a prison population, and compared their effectiveness in detecting hazardous drinking, harmful drinking, and possible alcohol dependence as classified by the full ten-item AUDIT. Methods The study sample included pre-prison drinkers who participated in the Norwegian Offender Mental Health and Addiction (NorMA) study (n = 758). We conducted receiver operating characteristic curve (ROC) analyses and estimated the area under the curve (AUROC) to assess the performance of AUDIT-C (three consumption items) and four-item versions that consisted of AUDIT-C and one additional item. Results AUDIT-C performed very well in detecting unhealthy drinking of varying severity (AUROCs of 0.933 or 0.935). Four-item versions performed even better. Of these, the well-established AUDIT-4 was superior in identifying harmful drinking (AUROC=0.969) and possible alcohol dependence (AUROC=0.976). For AUDIT-C, the optimal cut-points in terms of the highest combined sensitivity and specificity were ≥ 6 (hazardous drinking), ≥ 8 (harmful drinking) and ≥ 8 or ≥ 9 (possible dependence). The corresponding cut-points on AUDIT-4 were ≥ 6, ≥ 9 and ≥ 10. The highest cut-point whereby all cases of possible dependence were identified was ≥ 6 on AUDIT-C and ≥ 8 on AUDIT-4. At these cut-points, almost all individuals with harmful drinking were also detected. Conclusions AUDIT-C and AUDIT-4 were both highly effective in detecting hazardous drinking, harmful drinking and possible alcohol dependence. AUDIT-4 was superior, notably as a graded severity measure.

The NorMA cohort is a national cohort of inmates in Norwegian prisons that has formed the basis for a number of reports and scientific articles. But to what extent is the NorMA cohort representative of the Norwegian prison population? This question has been answered by a PhD candidate in the PriSUD project, Nicoline Toresen Lokdam, in a brand new article. In the PriSUD project, we work with several types of data and data sources. One of the basic cohorts in the project is the one we call the NorMA cohort. An important question to ask when working with data from cohorts is how well the cohort represents the population one wants to investigate. In this new article, we have therefore investigated how well the NorMA cohort reflects the general Norwegian prison population The article is based on questionnaire data from the NorMA study, combined with register data from the prison register (KOMPIS). The article has a methodological perspective that describes how data from registers can generally be used to assess whether data you work with is representative of the group you want to investigate. The article uses the NorMA cohort as an example, and thus also helps to shed light on how well the NorMA cohort represents the Norwegian prison population. The study compared the NorMA cohort's 733 participants, who served all over the Norway in 2013-2014, with an average of the entire Norwegian prison population on a single day during the same period. "We can see that the NorMA cohort is largely representative of the part of the Norwegian prison population that we would normally investigate with register data, namely those that have a valid Norwegian person number. The groups are similar in relation to prison history, prison time, convictions and drug-related sentences (such as "use and possession"). On the other hand, part of the NorMA study consists of persons who did not have a valid Norwegian person number and who we cannot follow through studies on the NorMA cohort», says Nicoline. «One of the strengths of the study is that we both have answers from the questionnaire survey of those who for various reasons did not provide a social security number, but also the prison's registrations of those without a social security number. Therefore, we have the opportunity to say something about how it affects our results if these people are not included. It is a great strength for further research on the NorMA cohort that one has knowledge of how the cohort represents the Norwegian prison population »says Nicoline. The article is published in the medical methodological journal Research Methods in Medicine and Health Science and can be read here.

Toresen Lokdam, Nicoline, Riksheim Stavseth, Marianne, and Bukten, Anne. "Exploring the External Validity of Survey Data with Triangulation: A Case Study from the Norwegian Offender Mental Health and Addiction (Norma) Study." Research Methods in Medicine & Health Sciences 2, no. 4 (2021): 140-47. https://doi.org/10.1177/26320843211061298. Objectives This paper demonstrates how to investigate the external validity of a study sample by triangulating survey and registry data, using data from the Norwegian Offender Mental Health and Addiction (NorMA) Study as a case. Methods We use survey data from the NorMA study (n = 1495), including the NorMA cohort (n = 733), and data from the Norwegian Prison Registry on all people imprisoned on 1 September 2013 (n = 3386). Triangulation was performed by (1) comparing the NorMA cohort to those lost to follow-up (n = 762), using survey data from the NorMA study. Secondly, we compared the NorMA cohort to the one-day population, using data from the Norwegian Prison Registry. We also stratified the one-day sample by possession of a Norwegian personal identification number (PIN). Results We found differences in birthplace, imprisonment and drug use between the NorMA cohort, lost to follow-up and the one-day population. Twenty-three percent of the one-day population did not have a Norwegian PIN. The NorMA cohort was more similar to those with a Norwegian PIN in the one-day population. Our triangulation demonstrates that 56–62% of the Norwegian prison population had an indication of drug use before imprisonment. Conclusions The NorMA cohort was overall representative of the one-day prison population holding a Norwegian PIN and less representative of prisoners without a Norwegian PIN. Using this method provides tangible inputs on the strengths and limitations of a study sample and can be a feasible method to investigate the external validity of survey data.

Welcome to our two new colleagues on the PriSUD project: Vegard Svendsen and Torill Tverborgvik! Vegard will work as a Ph.D. research fellow and will work with nPRIS data, including the use of social security data. Torill has started working in a postdoc position and will focus on Nordic cooperation in the PriSUD project. We are very happy to have even more talented people on board and very much looking forward to working with both!