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Kevin Fiscella, MD, MPH, Naomi Pless, MD, Sean Meldrum, MS and Paul Fiscella, JD

Kevin Fiscella, Naomi Pless, and Sean Meldrum are with the Department of Family Medicine, University of Rochester School of Medicine and Dentistry, Rochester, NY. Kevin Fiscella is also with the Department of Community and Preventive Medicine, University of Rochester School of Medicine and Dentistry. Paul Fiscella is in private law practice in Hampton, Va.

Correspondence: Requests for reprints should be sent to Kevin Fiscella, MD, MPH, Family Medicine Center, 885 South Ave, Rochester, NY 14620-2399 (e-mail: kevin_fiscella{at}urmc.rochester.edu).

	ABSTRACT

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We sought to estimate the number of arrestees at risk for inadequately treated drug and alcohol withdrawal in US jails. We used Arrestee Drug Abuse Monitoring Program data to estimate prevalence rates of alcohol and opiate dependence. Our results revealed rates of alcohol and opiate dependency among arrestees of approximately 12% and 4%, respectively; only 28% of jail administrators reported that their institutions had ever detoxified arrestees. Inadequately treated drug and alcohol withdrawal in US jails appears widespread. Our data raise important ethical and constitutional questions.

	INTRODUCTION

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Inadequately treated alcohol and drug withdrawal have been shown to contribute to deaths among newly arrested individuals.^1–8 Despite such findings, little attention has been focused on the availability of alcohol and drug detoxification among arrestees. In this study, we used published data to estimate the number of arrestees at risk for untreated alcohol or opiate withdrawal in US jails.

	METHODS

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We analyzed information obtained from the Arrestee Drug Abuse Monitoring (ADAM) Program to estimate numbers of arrestees with alcohol or opiate dependency. ADAM collects annual national data on urine toxicology and self-reported alcohol and drug dependency among arrestees in the United States. We estimated detoxification availability in jails in 1997 using data from a federally sponsored survey, the Uniform Data and Facility Set Survey of Correctional Facilities.⁹ Specifically, administrators were asked "Does your facility currently detoxify any of its inmates/residents/detainees from alcohol or drugs?" Finally, we estimated numbers of arrestees at risk for alcohol or opiate withdrawal by multiplying rates of self-reported dependence by estimates of detoxification availability.

	RESULTS

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Estimates of Alcohol Dependency
Community-specific median rates of self-reported alcohol dependency among arrestees in 1997 were 11% and 12% among men and women, respectively (Table 1).¹⁰ Using the methods of Hammett et al. to account for rearrests,¹¹ and based on an estimated figure of 15.2 million arrests in 1997,¹² we estimated that 11 million individuals were arrested in 1997 and that 1.2 million of these arrestees were alcohol dependent.

Estimates of Untreated Alcohol and Opiate Withdrawal
Only 28% of jail administrators reported that their jails provided alcohol or drug detoxification services. Among administrators reporting that their institutions had never provided such services, only 10% indicated that detoxification or drug treatment had been provided off-site.⁹ Smaller jails were less likely than larger jails to offer detoxification. After weighting of jail size estimates, results showed that 63% of all arrestees were detained in facilities reported as never detoxifying inmates. Thus, we estimate that roughly 756 000 (1 200 000 x 0.63) arrestees are at risk for untreated alcohol withdrawal, and 277 000 (440 000 x 0.63) are at risk for untreated opiate withdrawal.

	DISCUSSION

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Our findings suggest that roughly 1 million arrestees per year may be at risk for untreated alcohol or opiate withdrawal. Guidelines for alcohol and opiate detoxification have been established by the American Society of Addiction Medicine,¹⁵ the American Psychiatric Association,¹⁶ and the National Consensus Development Panel,¹⁷ and standards for jails and prisons in regard to management of withdrawal have been established by the National Commission on Correctional Health Care (NCCHC)¹⁸ and the Federal Bureau of Prisons.¹⁹ However, only 8% of US jails have obtained accreditation through NCCHC, and few jails are federally operated.

The present findings have implications for human rights, particularly in the case of members of minority groups, who are arrested at disproportionately high rates.²⁰ Withdrawal symptoms often begin before arrestees have been formally charged with a crime (which may take up to 72 hours²¹). Thus, arrest and detention may result in pain, suffering, and morbidity among alcohol- or opiate-dependent individuals who have not yet been charged with, much less convicted of, a crime. The implicit threat of withdrawal after detention may coerce arrestees into providing information they might not otherwise volunteer.²²

There are several caveats to our findings. First, national rates of dependence are based on extrapolations from ADAM data, which are compiled at the community level; weights necessary to generate reliable national estimates have not yet been developed. Second, self-reported dependency is a relatively crude measure of physiological dependence. Data on rates of severe withdrawal among arrestees are not available.

Third, the data we compiled regarding availability of detoxification in jails were based on responses to a single question. Conceivably, jail administrators may have misconstrued the question or been unaware of detoxification services provided in their institutions. However, research has shown that only 1% of inmates who admit abusing drugs or alcohol at the time of their arrest report receiving detoxification in jail.²³ Finally, we did not match community-specific rates of alcohol or opiate dependency with rates of detoxification availability. It is plausible that jails with higher rates of dependency are more likely to provide detoxification.

In conclusion, the data obtained in this study suggest that inadequately treated alcohol and opiate withdrawal are widespread in US jails. Although more reliable data are needed, our results suggest the need for national, enforceable standards in regard to alcohol and opiate detoxification in US jails.

	Acknowledgments

 
We thank Nancy Phillips for her comments and edits and Regina Powers, PhD, JD, for supplying us with special tabulations from the Uniform Facility Data Set Survey of Correctional Facilities data set (available from the Substance Abuse and Mental Health Services Administration upon request).

Human Participant Protection
No protocol approval was needed for this study.

	Footnotes

 
Contributors
K. Fiscella designed the project, conducted the literature review, supervised the analyses, and assisted with interpretation of the findings and the writing of the brief. N. Pless assisted with analyses, data interpretation, and the writing of the brief. S. Meldrum conducted the analyses and assisted in data interpretation and the writing of the brief. P. Fiscella assisted with interpretation of results and with the writing of the brief.

Peer Reviewed

Accepted for publication May 5, 2003.

	References

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1. Byrne M, Meinharrdt J. Inmate in jail’s medical unit dies. St. Petersburg Times. April 7, 2000:A1.

2. Lancaster v Monroe County, Alabama, 116 F3d 1419 (11th Cir 1997).

3. New York State Commission of Corrections. A death in Madison County. Available at: http://www.sic.state.ny.us/publication/Investigations/96-1.html. Accessed July 27, 2001.

4. Peterson v Traill County, 601 NW2d 268 (ND 1999).

5. American Civil Liberties Union of Colorado. ACLU sues El Paso county jail over death of inmate. Available at: http://www.aclu-co.org/news/pressrelease/release_spillane.htm. Accessed July 27, 2001.

6. Kocks J. Coroner: Wichita County jail inmate died of alcohol withdrawal. Times Record News. July 26, 2001:A1.

7. Thompson v Upshur County, Texas, 245 F3d 447 (5th Cir 2001).

8. Flanigan P. State hits Monroe in death of inmate. Democrat & Chronicle. March 30, 2001:A1, A7.

9. Substance Abuse Treatment in Adult and Juvenile Correctional Facilities: Findings From the Uniform Facilities Data Set 1997 Survey of Correctional Facilities. Rockville, Md: Substance Abuse and Mental Health Services Administration, Office of Applied Studies; 2000.

10. Arrestee Drug Abuse Monitoring Program: Adult Program Findings, 1997. Washington, DC: National Institute of Justice; 1997.

11. Hammett TM, Harmon MP, Rhodes W. The burden of infectious disease among inmates of and releasees from US correctional facilities, 1997. Am J Public Health. 2002;92:1789–1994.[Abstract/Free Full Text]

12. Department of Justice, Federal Bureau of Investigation. Uniform crime reports for the United States, 1997. Available at: http://www.fbi.gov/ucr/Cius_97/97crime/97crime.pdf. Accessed November 9, 2002.

13. Young L. Improving quality and oversight of methadone treatment. Available at: http://www.samhsa.gov/press/99/990722fs.htm. Accessed August 10, 2001.

14. Appel PW, Joseph H, Kott A, Nottingham W, Tasiny E, Habel E. Selected in-treatment outcomes of long-term methadone maintenance treatment patients in New York State. Mt Sinai J Med. 2001;68:55–61.[Medline]

15. Mayo-Smith MF. Pharmacological management of alcohol withdrawal: a meta-analysis and evidence-based practice guideline. JAMA. 1997;278:144–151.[Abstract]

16. American Psychiatric Association. Practice guideline for the treatment of patients with substance use disorders: alcohol, cocaine, opioids. Am J Psychiatry. 1995;152(suppl):1–59.[ISI]

17. National Consensus Development Panel on Effective Medical Treatment of Opiate Addiction. Effective medical treatment of opiate addiction. JAMA. 1998;280:1936–1943.[Abstract/Free Full Text]

18. Standards for Health Services in Jails. Chicago, Ill: National Commission on Correctional Health Care; 1996.

19. Federal Bureau of Prisons. Clinical Practice Guidelines: Detoxification of Chemically Dependent Persons. Washington, DC: National Institute of Corrections; 2000:1–44.

20. Wolf Harlow C. Profile of Jail Inmates 1996. Washington, DC: Bureau of Justice Statistics; 1998.

21. Perkins CA, Stephan JJ, Beck AJ. Jails and Jail Inmates 1993–94: Census of Jails and Survey of Jails. Washington, DC: US Dept of Justice; 1995.

22. Goldfarb R. Jails: The Ultimate Ghetto. Garden City, NY: Doubleday; 1975.

23. Wilson DJ. Drug Use, Testing, and Treatment in Jails. Washington, DC: Bureau of Justice Statistics; 2000.

This Article Abstract Full Text (PDF) Submit a response Purchase Article View Shopping Cart Alert me when this article is cited Alert me when eLetters are posted Alert me if a correction is posted Services Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Fiscella, K. Articles by Fiscella, P. Search for Related Content PubMed PubMed Citation Articles by Fiscella, K. Articles by Fiscella, P. Related Collections Prevention Screening Alcohol Drugs