Self-Reported Alcohol and Drug Problems Among Internal Medicine Outpatients: Relationships With Criminal Behavior

Self-Reported Alcohol and Drug Problems Among Internal Medicine Outpatients: Relationships With Criminal Behavior

Randy A. Sansone, MD; Charlene Lam, MD, MPH; and Michael W. Wiederman, PhD

Relationships between alcohol/drug misuse and criminal behavior have been reported for over 30 years.1 In this regard, a number of empirical studies in the United States have verified this relationship in different types of substance-using samples, including those misusing various substances,2-5 alcohol,6-8 methamphetamine,9,10 and heroin,11 as well as in samples of community dwellers.12-14 Likewise, several international studies have examined and confirmed relationships between alcohol/drug misuse and crime in abusers of various and multiple substances,15,16 alcohol,17 and cocaine18 and in community samples.19-22

Despite various types of samples, forms of substance misuse, and measures of criminality, all of the preceding studies have confirmed relationships between alcohol/substance misuse and criminality. However, we were not able to locate any studies of this relationship in a clinical or primary care sample. Such sampling differences are important in terms of anticipating clinical phenomena in various populations. In addition, among studies undertaken in the United States, we noted a number of potential limitations, including the examination of alcohol misuse only12 or drug misuse only14 and exploration of only 9 illegal behaviors.13 However, in 1 community study,13 which is the most methodologically similar to the present study, males were 2.5 to 3.4 times more likely to demonstrate an association between alcohol/substance misuse and criminal behavior than were females. In the present study, we examined relationships between self-reported alcohol or drug problems and charges for any of 27 criminal behaviors and hypothesized that there would be a relationship between these variables, particularly in males.

METHOD

Participants

Participants were men and women, aged 18 years or older, being seen for nonemergent medical care at an outpatient internal medicine clinic staffed predominantly by residents and located in a midsized, midwestern city in October 2010. After excluding individuals who initially appeared unable to successfully complete a survey (eg, excessive pain, psychosis, dementia), 471 individuals were approached and 417 agreed to participate, for a participation rate of 88.5%. Of these participants, 376 completed all study measures: 129 (34.3%) men and 247 (65.7%) women, who ranged in age from 19 to 97 years (mean = 50.14, SD = 15.39). Most respondents (88.0%) were white, followed by black (7.7%), other (2.1%), Hispanic (1.3%), and Asian (0.8%). All but 6.2% of respondents reported having at least attained a high school diploma; 14.8% had a bachelor’s degree and 13.4% had a graduate or professional degree.

• According to past empirical studies, there is a relationship between alcohol/drug misuse and criminality, but this relationship has never been explored in a primary care sample.
• In this study, we found that men with alcohol and/or drug problems statistically exhibited the greatest number of charges for illegal behavior.
• Compared to participants who did not endorse alcohol/drug problems, those who did were statistically more likely to be charged with several related crimes (eg, driving under the influence, drug abuse violations, drunkenness) and otherwise (eg, aggravated assault, simple assault, disorderly conduct).

To characterize this clinic, during the year 2008, 64% of the consultations were for women; 30% of patients were between the ages of 15 and 44 years, 45% were between the ages of 45 and 64 years, and 25% were aged 65 years or older; and 8% were self-pay, 49% had government insurance (Medicare/Medicaid), and 43% had private insurance. The most common clinical diagnoses were hypertension (8.7%), hyperlipidemia (6.1%), diabetes (5.4%), allergies (4.7%), and hypothyroidism (2.3%). Note that the gender proportions of the current sample mirror the general population of patients being seen at this clinic.

Procedure

During clinic hours, one of the authors (C.L.) positioned herself in the lobby of the clinic, approached consecutive incoming patients, and informally assessed exclusion criteria. The recruiter reviewed the focus of the project and then invited each potential participant to complete a 5-page survey that took about 10 minutes. Participants were asked to place completed surveys into sealed envelopes and then into a collection box in the lobby.

The survey consisted of the following 3 sections:

1. A demographic query.
2. Exploration of past alcohol and drug problems assessed through 2 questions that are typical exploratory queries in the clinical setting, “Have you ever had a problem with alcohol?” and “Have you ever had a problem with drugs?” (with yes/no response options).
3. A query about charges for past illegal behavior (“Have you ever been charged with, not necessarily convicted of, any of the following crimes?”), using a 27-item, yes/no, author-developed inventory that is based on the crime-cataloguing schema used by the US Federal Bureau of Investigation.23 Importantly, this schema does not include routine traffic offenses.

This project was reviewed and exempted by the institutional review boards of the community hospital wherein the study took place as well as by the local university. Participants were informed that completion of the survey functioned as implied consent, which was specifically clarified on the cover page of the survey. There was no funding for this study.

RESULTS

Of the 376 respondents, 83 (22.1%) reported having had problems with alcohol (n = 66, 17.6%) and/or drugs (n = 58, 15.4%). Men were more likely to report having had problems with alcohol compared to women (23.3% vs 14.6%, respectively, χ2 = 4.41, P < .03) and drugs (20.2% vs 13.0%, respectively, χ2 = 3.37, P < .05).

Of the 27 illegal behaviors examined, the number endorsed by each respondent ranged from 0 to 13 (mean = 0.56, SD = 1.63), with most participants (78.7%) reporting none of the listed behaviors. Because only 6 respondents endorsed 7 or more illegal behaviors, there was the possibility that these few relatively extreme respondents might have an undue influence on the results of subsequent analyses. To correct for this possibility, scores on the measure of illegal behaviors were truncated at 7 (for those 6 respondents who endorsed 7 or more behaviors). On this truncated measure, men reported a greater number of different criminal charges (mean = 0.84, SD = 1.68) than did women (mean = 0.34, SD = 1.04, F1,374 = 12.94, P < .001).

To examine the potential relationship between alcohol/drug misuse and illegal behavior, we performed a series of 3 analyses of variance for which respondent sex and history of alcohol and/or drug misuse were independent variables and score on the truncated measure of illegal behaviors was the dependent variable (Table 1). With regard to alcohol misuse, there were statistically significant main effects for sex and for history of alcohol misuse (P < .001). As expected, respondents with a history of alcohol misuse reported a greater number of different forms of illegal behavior (mean = 1.85, SD = 2.11, n = 66) compared to respondents without a history of alcohol abuse (mean = 0.23, SD = 0.83, n = 310). However, both main effects were subsumed by a statistically significant interaction between sex and history of alcohol misuse (P < .03), with men reporting a history of alcohol misuse also reporting the greatest number of different illegal behaviors.

With regard to drug misuse, there were statistically significant main effects for sex and for history of drug misuse (P < .001). Compared to respondents without a history of drug misuse (mean = 0.25, SD = 0.85, n = 318), respondents with a history of drug misuse reported a greater number of different charges for illegal behavior (mean = 1.93, SD = 2.21, n = 58). However, both main effects were subsumed by a statistically significant interaction between sex and history of drug misuse (P < .03), with men reporting a history of drug misuse also reporting the greatest number of different illegal behaviors.

Finally, to investigate the types of illegal behaviors behind the apparent difference in total number by respondents who reported a history of alcohol/substance misuse compared to respondents who did not, we examined the rates of endorsement for each illegal behavior as a function of alcohol/substance misuse history. Respondents who reported a history of alcohol misuse and/or drug misuse (n = 83) were compared to respondents who denied either form of misuse (n = 293) (Table 2). Given the large number of comparisons, we chose P < .001 as the effective significance level. Respondents with a history of alcohol/substance misuse reported higher rates of charges on 9 of the 27 different illegal behaviors. Some of these differences were directly related to alcohol/substance misuse, while some were not.

CONCLUSIONS

According to our study findings, there is a relationship between alcohol/drug problems and the number of charges for different illegal behaviors reported, specifically among men being seen in a primary care clinic. This finding, elicited in an entirely different type of study sample to date and through a broad inquiry about illegal behaviors, resonates with the current literature, particularly with regard to gender patterns, and reinforces the importance of routinely questioning patients with alcohol/substance problems about past histories of illegal behavior, particularly with regard to social and legal implications.

In this study, some of the reported charges were directly related to alcohol/substance misuse, such as driving under the influence of alcohol or drugs, drug abuse violations, and drunkenness. However, some reported charges were not directly related, such as aggravated assault and simple assault. It is not clear from these data whether these latter behaviors are indirectly related to alcohol/substance abuse (eg, intoxication with subsequent assaultive behavior) or independent of alcohol/substance misuse (ie, behaviors associated with antisocial features).

This study has a number of potential limitations. First, the data are self-report in nature. Because of this, it is highly likely that a number of participants were either unwilling to acknowledge or denied having alcohol/drug problems—a well-known characteristic feature of addiction. Second, we used a nonstandardized inquiry about alcohol/drug problems (an approach we elected in an effort to mirror typical inquiries in the clinical setting). Third, two-thirds of the participants in this sample were women. While this proportion reflects the service profile for this clinic, the strength of statistical analyses may have been more robust with a larger proportion of men, as they tend to have higher rates of alcohol/substance misuse in general. Fourth, we do not know the temporal relationship between alcohol/substance misuse and illegal behaviors and therefore cannot speculate about possible causal relationships between the two (we did not collect these data). Finally, we do not know the gender profile of participants who declined to participate, as we did not record these data. However, in reviewing this concern with the recruiter, she did not believe that there was a refusal pattern related to gender (ie, she did not perceive that more men than women refused to participate).

In terms of the distinctive aspects of this study, the present sample was consecutive in nature and reasonably large, and findings are from a population that is unique to the literature. These data suggest that in primary care populations, there are likely to be relationships between alcohol/drug problems and the number of charges for different illegal behaviors, particularly among men—an association that needs to be explored in such patients, particularly in terms of social and legal implications.

Author affiliations: Departments of Psychiatry and Internal Medicine, Wright State University School of Medicine, Dayton, Ohio (Dr Sansone); Kettering Medical Center, Kettering, Ohio (Drs Sansone and Lam); and Department of Human Relations, Columbia College, Columbia, South Carolina (Dr Wiederman).

Potential conflicts of interest: None reported.

Funding/support: None reported.

REFERENCES

1. Fink L, Hyatt MP. Drug use and criminal behavior. J Drug Educ. 1978;8(2):139-149. doi:10.2190/L6U3-NURL-C67V-L0QV

2. Friedman AS, Glassman K, Terras BA. Violent behavior as related to use of marijuana and other drugs. J Addict Dis. 2001;20(1):49-72. PubMed doi:10.1300/J069v20n01_06

3. Greene BT. An examination of the relationship between crime and substance use in a drug/alcohol treatment population. Int J Addict. 1981;16(4):627-645. PubMed

4. Kinlock TW, Battjes RJ, Gordon MS. Factors associated with criminal severity among adolescents entering substance abuse treatment. J Drug Issues. 2004;34:293-318.

5. Spunt B, Brownstein HH, Crimmins SM, et al. Drugs and homicide by women. Subst Use Misuse. 1996;31(7):825-845. PubMed doi:10.3109/10826089609063959

6. Martin RL, Cloninger CR, Guze SB. Alcoholism and female criminality. J Clin Psychiatry. 1982;43(10):400-403. PubMed

7. Schmidt L. A profile of problem drinkers in public mental health services. Hosp Community Psychiatry. 1992;43(3):245-250. PubMed

8. Webster JM, Oser CB, Mateyoke-Scrivner A, et al. Drug use and criminal activity among rural probationers with DUI histories. Int J Offender Ther Comp Criminol. 2009;53(6):717-730. PubMed doi:10.1177/0306624X08323615

9. Booth BM, Leukefeld C, Falck R, et al. Correlates of rural methamphetamine and cocaine users: results from a multistate community study. J Stud Alcohol. 2006;67(4):493-501. PubMed

10. Brecht M-L, Greenwell L, Anglin MD. Substance use pathways to methamphetamine use among treated users. Addict Behav. 2007;32(1):24-38. PubMed doi:10.1016/j.addbeh.2006.03.017

11. Harrington P, Cox TJ. A twenty-year follow-up of narcotic addicts in Tucson, Arizona. Am J Drug Alcohol Abuse. 1979;6(1):25-37. PubMed doi:10.3109/00952997909007030

12. Ellickson PL, Tucker JS, Klein DJ. Ten-year prospective study of public health problems associated with early drinking. Pediatrics. 2003;111(5, pt 1):949-955. PubMed doi:10.1542/peds.111.5.949

13. Greenfield TK, Weisner C. Drinking problems and self-reported criminal behavior, arrests and convictions: 1990 US alcohol and 1989 county surveys. Addiction. 1995;90(3):361-373. PubMed doi:10.1111/j.1360-0443.1995.tb03784.x

14. Newcomb MD, Galaif ER, Carmona V. The drug-crime nexus in a community sample of adults. Psychol Addict Behav. 2001;15(3):185-193. PubMed doi:10.1037/0893-164X.15.3.185

15. Byqvist S, Olsson B. Male drug abuse, criminality and subcultural affiliation in a career perspective. J Psychoactive Drugs. 1998;30(1):53-68. PubMed

16. Gossop M, Marsden J, Stewart D, et al. Substance use, health and social problems of service users at 54 drug treatment agencies: intake data from the National Treatment Outcome Research Study. Br J Psychiatry. 1998;173(2):166-171. PubMed doi:10.1192/bjp.173.2.166

17. Hagg×¥rd-Grann U, Hallqvist J, L×¥ngström N, et al. The role of alcohol and drugs in triggering criminal violence: a case-crossover study. Addiction. 2006;101(1):100-108. PubMed doi:10.1111/j.1360-0443.2005.01293.x

18. Shearer J, Johnston J, Fry CL, et al. Contemporary cocaine use patterns and associated harms in Melbourne and Sydney, Australia. Drug Alcohol Rev. 2007;26(5):537-543. PubMed doi:10.1080/09595230701499159

19. Pedersen W, Skardhamar T. Cannabis and crime: findings from a longitudinal study. Addiction. 2010;105(1):109-118. PubMed doi:10.1111/j.1360-0443.2009.02719.x

20. Richardson A, Budd T. Young adults, alcohol, crime and disorder. Crim Behav Ment Health. 2003;13(1):5-16. PubMed doi:10.1002/cbm.527

21. Rydelius PA. Alcohol-abusing teenage boys: testing a hypothesis on the relationship between alcohol abuse and social background factors, criminality and personality in teenage boys. Acta Psychiatr Scand. 1983;68(5):368-380. PubMed doi:10.1111/j.1600-0447.1983.tb07019.x

22. Stenbacka M, Stattin H. Adolescent use of illicit drugs and adult offending: a Swedish longitudinal study. Drug Alcohol Rev. 2007;26(4):397-403. PubMed doi:10.1080/09595230701373875

23. Federal Bureau of Investigation. Uniform Crime Reporting Handbook. http://www.fbi.gov/about-us/cjis/ucr/additional-ucr-publications/ucr_handbook.pdf. Accessed October 13, 2011.