Stimulant use on the rise in jail population

Virtually everyone is aware of what has been called the opioid epidemic in the United States. Indisputably, opioid use and opioid use disorders are much more prevalent now than in the past. What is not realized with the preoccupation with just one substance is that policy-makers are overlooking a much larger and complex problem.

Prison populations and recent arrestees in local jails provide an indication of the relative prevalence of a range of substances in high-risk groups. From the 1980s to recent years, the most prevalent substance use disorders in both prison and jail populations involved alcohol, followed by cannabis use disorders. During the “cocaine epidemic” a few decades ago, cocaine became a more prevalent substance of concern. Unfortunately, there are few credible studies on the exact prevalence in correctional populations, due to the use of fallible screens instead of systematic diagnostic assessments.

Nonetheless, the relative prevalences that can be imputed from the studies that are available indicate that local jails have higher prevalence rates for substance use than prison populations. This may be due to diversions and other dispositions from jails. Jails act as gateways to the criminal justice system, possessing all arrestees, whereas prison populations are made up of a filtered adjudicated population.

With respect to jail populations, a 2008 study in an adjacent North Carolina county to the site of our current study demonstrated that alcohol, cocaine and cannabis were the most prevalent substances among recently arrested individuals. However, jail data collected in 2016 revealed a remarkable difference.¹ The most prevalent serious DSM-5 substance use disorder was for stimulants (38%), followed by opioids (28%) and alcohol (24%).

These statistics are for those with a severe use disorder, but based on the diagnostic interview, 85% of recently arrested individuals met criteria for some level of DSM-5 diagnosis. Both jail samples were drawn from jurisdictions covering similar largely rural populations, and both study results are based on the DSM-5 as indicated by the Comprehensive Addictions and Psychological Evaluation-5 (CAAPE-5), a structured diagnostic interview.

Stimulants have emerged

Despite all the current publicity about opioids and the risks inherent in opioid use, our findings suggest that among recent arrestees, stimulants account for the more prevalent substance use disorders. While one study cannot definitively determine prevalence, other indications are that stimulant use disorders are actually more prevalent than expected and continue to be overshadowed and overlooked.

Some of the increased methamphetamine production and use that is being seen may be associated with the switch in ingredients from pseudoephedrine to phenylacetone, which is still available in Mexico. Centers for Disease Control and Prevention (CDC) data in the National Vital Statistics Report of 2016 show that meth-related overdoses more than doubled between 2010 and 2014. The indications are clear that meth use and stimulant use disorders have shown a dramatic rise in recent years.

Perhaps the most shocking finding from the 2016 jail study was that nearly 40% of recent arrestees reported injecting some substance in the previous 12 months, and one-third were injecting regularly—typically with stimulants and/or opioids. Of the total number of inmates (n=283), 4% reported injecting opioids only; 14% were injecting stimulants only; and 20% were injecting both. Of those with a severe stimulant use disorder, 89% were injecting, compared to 85% of those with a severe opioid use disorder.

The bottom line is that based on the total number of cases or the proportion with a severe use disorder, more arrestees were injecting stimulants than opioids. Not only does injecting drug use pose a serious overdose risk, it also creates a public health issue in terms of spreading infectious disease. This would seem to be as significant an issue for stimulants as it is for opioids.

Details of current study

The CAAPE-5 interview used in the current study for a master’s thesis by one of this article's authors (A.R.) was typically completed in less than 30 minutes. (The study was funded in part by C4 Recovery Solutions.) In addition to substance use disorders, the interview covered common mental health conditions. The most prevalent mental health finding was that 48% of recent arrestees had indications of probable post-traumatic stress disorder (PTSD). The next most common conditions were major depression (35%) and panic attacks (29%). About 35% had indications of antisocial personality disorder. While only 11% had indications of bipolar disorder, this is considerably higher than the general base rate, and this is a condition that typically requires medication for long-term stability.

Thus, indications are that recently arrested adults detained in a local jail manifest a complex clinical profile, where the majority require some type of behavioral health services.

The initial objective of the current research was to assess the possible relationship between behavioral health conditions and criminal recidivism as indicated by repeated bookings in the local jail. About two-thirds of the individuals in the current study had at least one booking in the 12 months prior to the diagnostic interview. The strongest significant associations with recidivism were that those with multiple serious substance use disorders were more likely to have two or more bookings prior to the interview, and also were more likely to have subsequent bookings. Given the high rate of drug injection for stimulants and opioids, injection was also significantly correlated with repeated bookings.

Specifically, of those with multiple serious substance use disorders, 61% had multiple bookings prior to the interview, compared with 35% of those without multiple conditions. Similarly, 53% of those who had injected drugs had multiple prior bookings, compared with 38% who did not report injection. Recidivism has many adverse consequences for law enforcement resources, as well as for courts and other entities related to processing arrestees.

Bookings translate into days of incarceration, which entail substantial costs. The current research reviewed days of incarceration, if any, over the course of 24 months—12 months prior to the interview, days associated with the booking at the time of the interview, and 12 months after the interview. Of the total sample, 59 individuals were transferred to a state prison, which left 224 individuals eligible to be booked during the entire two-year time frame. These individuals accounted for a total of 13,502 days of incarceration. Since the typical cost for a day of incarceration in the county jail where the study was conducted is about $75, this amounts to a total of just over $1 million in basic costs for a county with a population of around 60,000.

This total does not include the costs for law enforcement officers' arrests, court costs, attorney’s fees, building maintenance, etc. More than a million dollars accrue simply for housing the inmates during their incarceration.

Of the 224 inmates in the analyses, 51 (23%) had both a moderate to severe stimulant use disorder and a moderate to severe opioid use disorder. These individuals were incarcerated for an average of approximately 82 days per individual during the two-year period, compared with an average of about 54 days per person for the 173 individuals who did not meet criteria for both conditions.

Another way of considering the impact of having a moderate to severe diagnosis for both stimulants and opioids is to consider average per-inmate costs. Those who had no moderate to severe stimulant or opioid use diagnosis had an average incarceration cost of $3,816 per inmate over the two-year period. The cost for inmates with a diagnosis for only one of the substances was $4,382; however, the average cost for those with a moderate to severe diagnosis for both substances was $6,123 per inmate. To the extent that treatment could address substance use disorders and reduce subsequent incarcerations, treatment might provide a reasonable return on investment for the services provided.

Clearly, stimulant use disorders appear to contribute to overdoses, risks for spreading infectious diseases, and public safety issues comparable to or greater than the impacts of opioid use disorders. Also, stimulant use disorders contribute to costs borne by local taxpayers, such as jail costs paid by county funds. Diverting adults from the criminal justice system to addiction treatment and related services coordinated with local law enforcement and jail administrators has the potential for significant cost savings, in addition to the potential human benefits.

Given the complexity of the clinical presentations seen, services must be capable of addressing co-occurring conditions. Screening and assessment tools are currently available for use with jail populations. What is lacking are the initiative and innovation to implement effective services.

Norman G, Hoffmann, PhD, is a clinical psychologist and recognized expert in clinical assessment and the evaluation of behavioral health programs. He has developed assessment instruments used throughout the United States, Canada, Sweden, Norway and the United Kingdom. He can be contacted at evinceassessment@aol.com.

Alyssa L. Raggio, MS, has a master's degree in clinical psychology from Western Carolina University. Her research focuses on mental health and substance use disorders in relation to recidivism among rural jail populations.

Albert M. Kopak, PhD, is a substance abuse researcher at Western Carolina University's Department of Criminology and Criminal Justice. He specializes in research related to the assessment and treatment of substance use disorders in criminal justice settings.

Kaitlin A. Guston received her MS in clinical psychology from Western Carolina University. Her primary research interests revolve around forensic risk assessment, patterns of offending, and the impact that substance use and trauma have on offending.

References

1. Raggio AL, Hoffmann NG, Kopak AM. Results from a comprehensive assessment of behavioral health problems among rural jail inmates. J Offender Rehab 2017; 56:217-35.