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.
The National Cocaine, Meth & Stimulant Summit is produced by the Institute for the Advancement of Behavioral Healthcare, the leading media and events producer in the behavioral healthcare field. The Institute also produces the National Rx Drug Abuse & Heroin Summit, the largest national annual gathering on the opioid crisis.