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As of June 2008, more than 13.6 million people passed through jails and prisons across the United States. In other words, one in every 131 people was incarcerated at some point during that year (US Bureau of Justice Statistics, 2009).
Inmates entering jail facilities report a myriad of acute and chronic health problems including hypertension, diabetes, asthma, epilepsy, acute and chronic pain and substance abuse disorders (Freudenberg, et al., 2007). With the rates of incarceration being so high, the odds are favorable that a certain prevalence of inmates will enter jail with reports of substance abuse and, in particular, prescription opiate abuse.
A common treatment for chronic pain disorders is the prescription of opioid medications. Sales of the most common prescribed opioid medications (oxycodone, codeine, oxycontin, methadone and others) have increased from 50.7 million grams to 126.5 million grams in the 10-year period from 1997 to 2007. Further, the NIH-sponsored 2008 National Survey on Drug Use and Health (NSDUH) revealed that approximately 20 million Americans, or eight percent of the population at the time reported a history of non-medical use of prescription drugs (using prescription drugs not actually prescribed to them) at some time in their lifetime. (Manchikanti, et al., 2010).
Scope of the Problem
Even though Americans make up a small percentage of the world population- just 4.6%- we use more than 80% of the world's supply of opiates and an astonishing 99% of the world's supply of hydrocodone. Moreover, Americans use over two-thirds of the global supply of illegal drugs such as cocaine, heroin, methamphetamines and marijuana. Of those reporting the non-medical use of prescription opiates in the NSDUH study, over 50 percent reported getting the drug free from a friend or relative, and in over 80% of the cases the opiates were prescribed to the friend or relative by a medical provider treating their chronic pain. 40% reported purchasing the drug from another person in exchange for money or other drugs (Manchikanti, et al., 2010).
It is estimated that 6 to 15 percent of the population in America abuses drugs of all types, and that illicit drug abuse and alcohol abuse leads to over 100,000 deaths annually (Ruetsch, 2010). It has been reported in the current literature that nearly 500 billion dollars are spent annually in the US on costs related to the medical and criminal affects of abuse of prescription drugs (including opiates and stimulants) and that the per-person healthcare costs between drug abusers and non-abusers is over $13,000 (Strassels,. 2009).
Jails tend to be concentration grounds for individuals with health problems, mental illness and substance abuse- most with co-occurring issues. According to a study in the New York City Jail, one of the county's largest jail systems, over 80 percent of female detainees and 50 percent of male detainees reported a history of illicit drug abuse on intake. Of those, 59.5% of women and 32.5% of men were incarcerated for drug possession or sales, 17.8% of women and 28.1% of males for property crimes including burglary, and 6.5% of women and 15.6% of men for crimes of violence against people such as robbery. (Freudenberg, et al., 2007). With a sample of nearly 2,000 inmates, the New York study can be easily generalizable to other jails across the country.
Because of the high concentration of substance abusers that become incarcerated, sites of incarceration such as county jails can provide a wealth of valuable information on the status of drug abuse within a community and factors that may be a result of, or contribute to, that abuse. The purpose of this paper will be to develop a study based at a large, urban county jail, to explore the prevalence of substance abuse (particularly prescription drug abuse) and its association with the actual, prescribed treatment of chronic pain (whether or not the opiate is prescribed to the detainee or not), the use of other illicit drugs (such as marijuana, cocaine and heroin), and the nature of the crime resulting in arrest (crimes of possession, violent crimes against people, and so on).
The conceptual framework of Richard Jessor's Problem-Behavior Theory would be appropriate for a study exploring the behavior of illicit drug use. The theory has been demonstrated in the empirical literature to be a predictor of psychosocial "proneness for involvement in problems behavior". The constructs within the theory of perceived environment, personality and behavior have the underlying premise of person and environment interaction causing behavior. In 1977, Jessor and Jessor reported "the key personality and perceived environmental variables have proved predictive of both cross-sectional and developmental variation, and, taken together, they usually account for between 30% an 50% of the variance in behaviors such as illicit drug use". (Jessor & Jessor, 1977).
Similarly, the Social Cognitive Theory of Albert Bandura has been used to describe the person-environment-behavior interaction and includes the concept of self-efficacy, or a person's perceived control over their behavior and may be used as an alternative conceptual framework for this study.
Research Questions and Hypotheses
Research questions proposed for this study are as follows:
Is the self-report of prescription drug abuse associated with the self-report of other illicit drug use (such as marijuana, cocaine, heroin, etc.)
Is the self-report of prescription drug abuse associated with the self-report of chronic pain disorders?
What type of crimes are those who report prescription drug abuse arrested for?
Proposed hypotheses are as follows:
Detainees who report prescription drug abuse do not report the abuse of any other illegal drugs.
Detainees who report prescription drug abuse do not report co-occurring chronic pain disorders.
Detainees who report prescription drug abuse are not arrested for crimes involving the possession or sale of illegal drugs, property crimes or violent crimes to people.
Whenever conducting research with inmates as subjects, certain ethical issues must be considered. First, the inmate population often have different health and social characteristics than the general population; recognition of and appreciation for these differences is crucial to understanding the population to be studied and for the development of instruments, interpretation of instruments, and building trust with research subjects. Secondly, several ethical considerations specific to the correctional population must be considered. The assurance of procedures for inmates to give informed consent prior to participation, the administration of instruments specifically written for participants of lower education and socioeconomic status, and the absolute prevention of any perceived coercion to participate in research are all significant ethical issues when planning a program of research with the incarcerated. (Freudenberg, 2005). To best collect the needed information for this study and to resolve major ethical issues regarding research with inmates, a chart-review format will likely be used.
The abuse of opiates, either prescribed or not prescribed, has serious implications on the health of the individual abuser, healthcare costs and public health of the community. Because substantial numbers of Americans become incarcerated annually, and the prevalence of reported substance abuse (notably prescription drug abuse) is high, jails can offer a wealth of information on the national burden of drug abuse. Exploration of the factors that may contribute to abuse and the social consequences of crimes committed as a result of substance abuse are highly important to the well-being of communities.