Today I will report on one of those “You ok? No, I’m not.” encounters.

During my recent foray to San Francisco I was hanging out at the parking lot of COIT Tower, while the film crew did some “B-roll” footage, recording scenes that can later be used in a documentary as background information, providing a sense of place.

Next to me, with both of us staring across the water at Alcatraz, was a middle-aged woman whose face was swollen from crying. (One of the reasons why there is no portrait today.)

I couldn’t help but ask if she was ok and the mere question elicited a torrent of revelations. A union rep, she had come to San Francisco from West Virginia 3 days earlier after her sister suddenly fell ill. A day later her sister died. Vicky had buried her father in law in February and lost her son, recently released from prison, to an overdose death in March.

She had come up to the tower to look at the social realist murals painted by students of Diego Rivera (quite a few women artists among them) in the early 1930s, radical political work that she had always wanted to see (Photographs below). But she was glued to the view of the prison, as was I, for far more personal reasons in her case than mine. Having sought distraction, she was right back at the central loss of this year, of her life, that of a child to opioids.

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Post-release opioid overdose mortality is at an all-time high and the leading cause of death for people released from jail or prison. There are many factors that contribute. I will try and summarize the current science, details can be found here.

Chronic pain, HIV and trauma, all prevalent among people who experienced incarceration, are linked to opioid use. So is the increased suicidality among the recently released, with a large number of overdoses being assumed to be intentional. The risk is increased by other factors: incarceration disrupted social networks, broke up families, increased poverty, interrupted health care access and led to stigma upon re-entry (something even more so experienced by Blacks than Whites, when looking at failed employment attempts and housing needs.) Re-entry into the community also often lays bare underlying psychiatric disorders and addiction problems that were partially contained while medicated in prison but also exacerbated by incarceration itself.

Solitary use is a risk factor for dying of an overdose as well. The majority of people who inject opioids after release from incarceration do so on their own and avoid social settings where help could be provided by someone near by, or where counteragents like Naxolone are available. People crave solitude after having no privacy whatsoever for every minute in prison. Then there is the loss of tolerance because of prison-induced abstinence over longer periods of time. People who used drugs before imprisonment and tolerated high doses, will die when they go back to those doses after periods of abstinence, because of dangerous levels of respiratory depression.

Generally there is little to no guaranteed access for post-release users to opioid use medication, given the pretense that people leave prison “clean.”

There are clear policy lessons implied. The lack of available Opioid Antagonist Therapy post-release needs to be remedied, first and foremost. Many of the people with addiction problems should not be in prisons in the first place, which increases trauma and health-related issues that lead to an increased risk of self-medication/regulation through further use. Treatment programs are the way to go (and, incidentally, cheaper than incarceration to society at large.) It would save a lot of families a lot of pain.

With this said, here is a classic.