• Slow Down, You’re Going Too Fast, Part I

    One of my favorite songs from the 1960s is “The 59th Street Bridge Song (Feelin’ Groovy),” originally released by Simon and Garfunkel in 1966. I was mesmerized by the lyrics, which I still sing daily on my morning walks along the desert trails.

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  • New Bills in the House Address SUDs and the Opioid Epidemic

    In April 2018, both the House Energy and Commerce Committee and the Senate Committee on Health, Education, Labor, and Pensions (HELP) advanced legislation to address the opioid epidemic. Addressed were issues pertaining to workforce, recovery residences, and medication-assisted treatment (MAT), among many others.

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Opiate Use: The Tip of the Iceberg for Adults in Jail

Feature Articles

Law enforcement officials and public health professionals are currently concentrating their efforts on reducing opiate use, and for good reason, but they may be overlooking even more prevalent substance use disorders (SUDs). The record number of fatal overdoses, the surge in treatment admissions, and the significant number of arrestees who test positive for opiates immediately following admission into local jails are all causes for concern (SAMHSA, 2017; Rudd, Aleshire, Zibbell, & Gladden, 2016; ONDCP, 2014; Kopak, Lawson, & Hoffmann, 2018).  However, focusing efforts strictly on this single group of SUDs can distract attention from the array of behavioral health needs observed among adults booked into local jails.

 

 
As researchers and clinicians, we may find it self-evident that our jail inmates experience a wide variety of behavioral health conditions. Despite this common understanding among those who work in this field, there is little empirical information available about this vulnerable population. Most of the data gathered from adults admitted to local jails is extremely vague, so much so that endorsement of the question, “Has a mental health professional ever told you that you have a mental disorder?” has been used by researchers as the threshold to estimate the prevalence of mental health disorders among inmates (Bronson & Berzofsky, 2017).

 

 
After learning about the scarcity of diagnostic information regarding the behavioral health needs of adult jail inmates, we initiated a research project to assess the most prevalent conditions in this population. This study filled in many obvious gaps by collecting data related to specific SUDs; affective, anxiety, and personality disorders; posttraumatic stress disorder (PTSD); and analyzing jail records to examine how these conditions may be related to persistent contact with the criminal justice system. It is also important to note that most of our current knowledge on the behavioral health of jail inmates comes from arrestees in large metropolitan areas. This information is valuable, but the largest proportion of jails in the US are in jurisdictions outside of major metropolitan areas (Ingram & Franco, 2014). Thus, this project was designed to collect data related to behavioral health indicators from a sample of adults detained in a rural county detention center located in Western North Carolina. The project began in December 2015 and the final behavioral health assessment was conducted in August 2016.

 

 
Gathering behavioral health data from inmates consisted of the administration of the Comprehensive Addiction and Psychological Evaluation-5 (CAAPE-5; Hoffmann, 2013). This assessment involves a structured interview, which begins by gathering demographic information from participants. This introductory section is followed by in-depth questioning related to criteria for SUDs and common mental health conditions consistent with the current version of The Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5; APA, 2013). The CAAPE-5 provides specific diagnostic information pertaining to a variety of SUDs including alcohol, marijuana, cocaine, heroin, stimulants, sedatives, hallucinogens, inhalants, and combinations of substances. The interview also covers major depression, mania, panic attacks, PTSD, and a number of personality disorders (e.g., obsessive compulsive, antisocial, paranoid, schizoid, borderline, and dependent). Depending on the number of positive findings, the interview takes approximately twenty to thirty-five minutes to complete.

 

 
Diagnostic information was collected within twenty-four to ninety-six hours of booking from a random sample comprised of 283 adult inmates. The majority (71 percent) of inmates who participated in the study identified as men, and most (85 percent) inmates reported their racial or ethnic background as white. The largest (10 percent) minority group was comprised of American Indian inmates. More than half (51 percent) of inmates reported never having been married and approximately one in five (19 percent) reported being divorced, with a similar proportion (18 percent) reported currently being married. Almost half (49 percent) of inmates received only a high school diploma or an equivalent education certificate, and approximately one-third (34 percent) did not complete high school. A substantial portion (48 percent) of inmates reported being unemployed at the time of admission into the jail, with nearly one-third (32 percent) reporting full-time employment. The average age of adults booked into the jail is nearly thirty-three years (32.8), with almost half (46 percent) of inmates between thirty-five and forty-four years of age.

 

 
In terms of SUD prevalence, results derived from the CAAPE-5 indicate the majority (85 percent) of inmates met criteria for at least one SUD and 68 percent had at least one serious SUD diagnosis. Closer examination shows that, among inmates who met criteria for at least one SUD, the most prevalent (53 percent) is amphetamine use disorder. This is followed in sequence by alcohol (39 percent), opiates (38 percent), and marijuana (19 percent). One-third (33 percent) of inmates reported injecting stimulants and/or opioids. Overdoses and transmission of disease are public health issues. While the severity of the opioid crisis should not be downplayed, jail inmates are likely to meet criteria for multiple moderate or severe SUDs, with amphetamines emerging as the most prevalent.

 

efi_15032388122_fig1

 

 

 
There is also no denying that adult inmates require adequate mental health services considering that 78 percent of those booked into the jail met criteria for at least one mental health condition. Overall prevalence rates were highest for PTSD (48 percent) and major depressive episode (48 percent). About one-third of inmates booked into the jail presented indications of antisocial personality disorder (35 percent) or experienced a manic episode (32 percent). Detailing this prevalence rate exclusively among the inmates who met criteria for a minimum of one mental health condition indicates there are similar rates of major depressive episodes (62 percent), PTSD (61 percent), and antisocial personality (60 percent). In other words, almost two-thirds of inmates who met criteria for at least one mental health condition experience depression, PTSD, and/or antisocial personality disorder. 

 

efi_15032388122_fig2

 

 

 
Given the prevalence of SUDs and mental health concerns among inmates, it comes as no surprise that most met criteria for a combination of these conditions. These data show two-thirds (64 percent) met criteria for at least one moderate or severe SUD plus at least one mental health condition. It is far less likely that inmates meet criteria for a moderate or severe substance use disorder (12 percent) or a mental health condition (15 percent) alone. It is also important to note the number of inmates who do not meet criteria for any SUD or report indications of a mental health condition are among the smallest (10 percent) proportion of adults booked into local jails. Simply stated, nearly all adult jail inmates have behavioral health needs and most present indications of multiple conditions. 

 

 
These prevalence rates are concerning because they provide a sense of the expansive behavioral health care needs of inmates. This becomes more troubling given the number of adults processed through local detention centers. Jail record data, which serve as a repository for prior booking and offense information, can be linked to behavioral health indicators to assess whether inmates who experience certain conditions are more likely to be booked into the jail on multiple occasions for specific types of offenses. Analysis of these data show larger proportions of inmates who present criteria consistent with moderate to severe SUDs and mental health conditions experience a greater likelihood of being admitted to the jail several times. The most pronounced association was that 60 percent of inmates with two or more severe SUDs had multiple prior bookings, compared to 35 percent of inmates without multiple severe SUD diagnoses. Nearly half (49 percent) of inmates who met criteria for multiple mental health conditions were also booked into the jail multiple times in the past twelve months. 

 

efi_15032388122_fig3

 

 
A similar pattern emerges when considering the types of offenses for which inmates were charged. The largest proportion of inmates charged with violent offenses is observed among those who meet criteria consistent with several mental health conditions. In this group of adults with several mental health problems, 17 percent were charged with violent offenses while 10 percent of inmates with multiple SUDs were charged with violent offenses. Inmates who met criteria for several severe SUDs were most likely to be charged with nonviolent offenses with over three-quarters (76 percent) falling into this category.  

 

 efi_15032388122_fig4

 

 
Clinical and Policy Implications

 

 
It is a well-known phenomenon that many local detention facilities lack the capability to identify and adequately address mental health and SUDs during the period in which inmates are incarcerated. This is due to minimal, if any, training for jail staff in the screening of prevalent conditions, unavailability of clinicians who can deliver the desperately needed services, and the likely lack of funding for such services (Parish, 2009). However, it is important for jail administrators and law enforcement officials to understand the role behavioral health conditions may play in the relatively high rates of recidivism seen in local detention facilities. In the current study, two out of three recent arrestees had been arrested and booked within the previous twelve months, and 43 percent had multiple prior bookings in that time. This is comparable to recent work which has documented similar rearrest rates (Durose, Cooper, & Snyder, 2014). 

 

 
Despite the high prevalence rates of behavioral health conditions in jails, SUDs and mental health conditions will continue to be overlooked in the absence of screening conducted by personnel who are not affiliated with law enforcement or corrections officers. Our prior research has shown that screening done by officers does not result in accurate reporting of behavioral health indicators (Proctor, Hoffmann, & Corwin, 2011). Recently arrested individuals may withhold information related to addictions from law enforcement officers for fear that the information will be used against them. However, providing trained professionals who are not sworn officers to conduct screening, assessment, and services in local detention centers can create additional legal, logistic, and financial challenges in addressing the needs of offenders. Budgets for local detention facilities typically do not include funding for clinicians to address the behavioral health needs of inmates (Applegate & Sitren, 2008).

 

 
Treatment providers seeking to deliver services in local jails also face legal, logistic, and financial challenges. Stationing clinicians at the jail, for example, may not be feasible. Even if clinicians are available, there is the potential problem that the assessment of conditions will complicate or interfere with the legal disposition of the case. For example, offenders’ attorneys may seek to be included in the process or representatives from the prosecutor’s office may need to be involved to prevent compromising inmates’ rights. There is also the issue of whether inmates will have health care coverage for treatment. It is likely that inmates will not have any coverage for services, so alternative strategies would be required to provide coverage or otherwise pay for assessment and treatment services. Given the fact that a substantial proportion of recent arrestees spend a short and indeterminate time in jails, some mechanism to continue services after release adds yet another complication.

 

 
Discussion

 

 
Despite challenges inherent in conducting screening, assessment, and treatment of offenders incarcerated in local detention centers and jails, realistic policies and practices that address these unmet needs are available.  

 

 
First, inmates can be screened for SUDs in an efficient manner. The six-item UNCOPE screen has been validated for the detection of severe SUDs on recent arrestees in both adult and juvenile systems, provided that the questions are not asked by uniformed officers. Additionally, inmates can easily be screened for PTSD and depression, which are two of the most prevalent mental health conditions observed among adult inmates. We have identified two, brief, two-item screens which can accurately identify inmates’ likelihood of experiencing PTSD or depression. Since all jails are required to have nursing and medical staff readily available, having nurses conduct the screening would be a logical option. Some institutions also have social workers available to work with inmates. This would provide another mechanism for screening and possibly an initial brief assessment.

 

 
The greater challenge is how to engage inmates in treatment services during the current period of incarceration or immediately upon release. Even if inmates express interest in treatment, simple referrals to providers are likely to be ineffective. A “warm handoff,” where inmates meet clinicians or interventionists while incarcerated and then are escorted to the programs or clinicians for services after release, is much more likely to result in a continuation of services. Other strategies, such as providing an interactive journal designed to facilitate the initial contemplation of treatment, have been shown to reduce recidivism via structured exercises whereby inmates are guided through the process of evaluating how substance use is related to offending (Proctor, Hoffmann, & Allison, 2012).

 

 
Finally, innovative strategies need to be considered for funding clinical services. Local governments—both county and city entities—are typically responsible for funding the community’s law enforcement services and detention centers. Offending by those with severe SUDs and other mental health conditions presents not only a public safety issue, but also a financial burden. Every arrest and booking occupies officers’ time and incurs significant costs for incarceration and court proceedings, all of which are typically borne by local government.  The majority of offenses committed by those with severe SUDs are nonviolent misdemeanors, primarily drug possession, driving under the influence, and theft (Kopak & Hoffmann, 2014). However, the cost per day to incarcerate such low-level nonviolent offenders is the same as for violent felons (Mai & Subramanian, 2017). 

 

 
To the extent that providing treatment services can reduce reoffending and incarceration time, the cost of providing behavioral health services will be offset, at least in part, by other societal savings. Additionally, reductions in the injection of drugs addresses public health risks.  

 

 
Reallocating budgets for assessment and treatment of behavioral health conditions can easily be viewed as a sound investment for the potential of net savings as well as enhancing public safety and public health. Making local officials aware of the potential return on these investments and contribution to public well-being requires thinking outside of the box.

 

 
 

 

 

 

 
 
 
References

 

American Psychiatric Association (APA). (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.
 
Applegate, B. K., & Sitren, A. H. (2008). The jail and the community: Comparing jails in rural and urban contexts. The Prison Journal, 88(2), 252–69.
 
Bronson, J., & Berzofsky, M. (2017). Indicators of mental health problems reported by prisoners and jail inmates, 2011–12. Retrieved from https://www.bjs.gov/content/pub/pdf/imhprpji1112.pdf
 
Durose, M. R., Cooper, A. D., & Snyder, H. N. (2014). Recidivism of prisoners released in thirty states in 2005: Patterns from 2005 to 2010. Retrieved from https://www.bjs.gov/content/pub/pdf/rprts05p0510.pdf 
 
Hoffmann, N. G. (2013). CAAPE-5 (comprehensive addictions and psychological evaluation-5). Carson City, NV: The Change Companies.
 
Ingram, D. D., & Franco, S. J. (2014). 2013 NCHS urban-rural classification scheme for counties. Retrieved from https://www.cdc.gov/nchs/data/series/sr_02/sr02_166.pdf
 
Kopak, A. M., & Hoffmann, N. G. (2014). The association between drug dependence and drug possession charges. Drugs and Alcohol Today, 14(2), 87–95.
 
Kopak, A. M., Lawson, S. W., & Hoffmann, N. G. (2018). Criminal justice contact and relapse among patients seeking treatment for opioid use disorder. Journal of Drug Issues, 48(1), 134–47
 
Mai, C., & Subramanian, R. (2017). The price of prisons: Examining state spending trends, 2010–2015. Retrieved from https://storage.googleapis.com/vera-web-assets/downloads/Publications/price-of-prisons-2015-state-spending-trends/legacy_downloads/the-price-of-prisons-2015-state-spending-trends.pdf 
 
Office of National Drug Control Policy (ONDCP). (2014). ADAM II: 2013 annual report. Retrieved from https://obamawhitehouse.archives.gov/sites/default/files/ondcp/policy-and-research/adam_ii_2013_annual_report.pdf
 
Parish, C. (2009). Survey reveals crisis in prison mental health in-reach services. Mental Health Practice, 12(8), 6. 
 
Proctor, S. L., Hoffmann, N. G., & Allison, S. (2012). The effectiveness of interactive journaling in reducing recidivism among substance dependent jail inmates. International Journal of Offender Therapy and Comparative Criminology, 56(2), 317–32.
 
Proctor, S. L., Hoffmann, N. G., & Corwin, C. J. (2011). Response bias in screening county jail inmates for addictions. Journal of Drug Issues, 41(1), 117–34.
 
Rudd, R. A., Aleshire, N., Zibbell, J. E., & Gladden, R. M. (2016). Increases in drug and opioid overdose deaths–United States, 2000–2014. Morbidity and Mortality Weekly Report, 64(50), 1378–82.
 
Substance Abuse and Mental Health Services Administration (SAMHSA). (2017). Treatment episode data set (TEDS): 2005–2015. National admissions to substance abuse treatment services. Retrieved from https://www.samhsa.gov/data/sites/default/files/2015_Treatment_Episode_Data_Set_National/2015_Treatment_Episode_Data_Set_National.pdf