RESEARCH AND PRACTICE
43. Kalkstein LS, Davis RE. Weather and human mortality: an evaluation of demographic and interregional responses in the United States. Ann Assoc Am Geogr. 1989;79:44–64. 44. Kalkstein LS. Health and climate change: direct impacts in cities. Lancet. 1993;342(8884):1397–1399. 45. Bridger CA, Helfand LA. Mortality from heat during July 1966 in Illinois. Int J Biometeorol. 1968;12:51–70. 46. Marmor M. Heat wave mortality in New York City, 1949 to 1970. Arch Environ Health. 1975;30: 130–136. 47. Greenberg JH, Bromberg J, Reed CM, Gustafson TL, Beauchamp RA. The epidemiology of heat-related deaths, Texas—1950, 1970–79, and 1980. Am J Public Health. 1983;73:805–807.
ern United States: learning from the lessons of 1995. Bull Am Meteorological Soc. 2001;82:1353–1367.
METHODS
63. Semenza JC, Rubin CH, Falter KH, et al. Heatrelated deaths during the July 1995 heat wave in Chicago [see comments]. N Engl J Med. 1996;335:84–90.
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.
64. Kaiser R, Rubin CH, Henderson AK, et al. Heatrelated death and mental illness during the 1999 Cincinnati heat wave. Am J Forensic Med Pathol. 2001; 22:303–307. 65. US Senate Special Commission on Aging. Heat Stress and Older Americans: Problems and Solutions. Washington, DC: US Government Printing Office; 1983.
48. Ellis FP. Mortality from heat illness and heataggravated illness in the United States. Environ Res. 1972;5:1–58. 49. Kizer KW. Lessons learned in public health emergency management: personal reflections. Prehospital Disaster Med. 2000;15:209–214. 50. Weisskopf MG, Anderson HA, Foldy S, et al. Heat wave morbidity and mortality, Milwaukee, Wis, 1999 vs 1995: an improved response? Am J Public Health. 2002;92:830–833. 51. Rajpal RC, Weisskopf MG, Rumm PD, et al. Wisconsin, July 1999 heat wave: an epidemiologic assessment. Wis Med J. 2000;99:41–44. 52. Dematte JE, O’Mara K, Buescher J, et al. Nearfatal heat stroke during the 1995 heat wave in Chicago [see comments]. Ann Intern Med. 1998;129: 173–181. 53. Robinson PJ. On the definition of a heat wave. J Appl Meteorology. 2001;40:762–775. 54. Steadman RG. The assessment of sultriness, part I: a temperature humidity index based on human physiology and clothing science. J Climate Appl Meteorology. 1979;18:861–873. 55. Steadman RG. A universal scale of apparent temperature. J Climate Appl Meteorology. 1984;23:1674–1687. 56. Semenza JC. Are electronic emergency department data predictive of heat-related mortality? [letter; comment]. J Med Syst. 1999;23:419–421, 423–424. 57. Kalkstein LS. A new approach to evaluate the impact of climate on human mortality. Environ Health Perspect. 1991;96:145–150. 58. Kalkstein LS, Greene JS. An evaluation of climate/ mortality relationships in large U.S. cities and the possible impacts of a climate change. Environ Health Perspect. 1997;105:84–93. 59. Sheridan SC, Kalkstein LS. Health watch/warning systems in urban areas. World Resource Review. 1998; 10:375–383. 60. Kalkstein LS, Greene JS, Libby J, Robinson L. The Philadelphia hot weather-health watch/warning system: development and application, summer 1995. Bull Am Meteorological Soc. 1996;77:1519–1528. 61. Whitman S, Good G, Donoghue ER, Benbow N, Shou W, Mou S. Mortality in Chicago attributed to the July 1995 heat wave. Am J Public Health. 1997;87: 1515–1518. 62. Palecki MA, Chagnon SA, Kunkel KE. The nature and impacts of the July 1999 heat wave in the midwest-
Alcohol and Opiate Withdrawal in US Jails | Kevin Fiscella, MD, MPH, Naomi Pless, MD, Sean Meldrum, MS, and Paul Fiscella, JD
RESULTS 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. (Am J Public Health. 2004;94:1522–1524)
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.
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Estimates of Alcohol Dependency Community-specific median rates of selfreported 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 Opiate Dependency The community-specific median rate of self-reported opiate dependency in 1997 was 4% among both men and women,10 corresponding to roughly 440 000 opiate-dependent arrestees (11 000 000 × 0.04; Table 1). This figure is consistent with an estimated 500 000 heroin addicts not enrolled in methadone programs13 and an average of nearly 1 arrest per year per addict.14
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 pro-
American Journal of Public Health | September 2004, Vol 94, No. 9
RESEARCH AND PRACTICE
TABLE 1—Estimates of Alcohol and Opiate Dependency Among Arrestees, by Gender: United States, 1997 Gender
Total No. of Arrestees
Male Female Total
8 600 000 2 400 000 11 000 000
Alcohol-Dependent Arrestees, No. (%) 950 000 (11) 290 000 (12) 1 240 000 (11)
Opiate-Dependent Arrestees, No. (%) 340 000 (4) 96 000 (4) 440 000 (4)
Contributors
Note. Totals may not be exact owing to rounding.
vided 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 × 0.63) arrestees are at risk for untreated alcohol withdrawal, and 277 000 (440 000 × 0.63) are at risk for untreated opiate withdrawal.
DISCUSSION 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.
About the Authors 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.
September 2004, Vol 94, No. 9 | American Journal of Public Health
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@ urmc.rochester.edu). This brief was accepted May 5, 2003.
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.
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.
References 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.
Fiscella et al. | Peer Reviewed | Research and Practice | 1523
RESEARCH AND PRACTICE Standard Methods For the Examination of Dairy Products
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.
Edited by H. Michael Wehr, Phd, and Joseph F. Frank, Phd
13. Young L. Improving quality and oversight of methadone treatment. Available at: http://www.samhsa. gov/press/99/990722fs.htm. Accessed August 10, 2001.
T
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. 15. Mayo-Smith MF. Pharmacological management of alcohol withdrawal: a meta-analysis and evidencebased practice guideline. JAMA. 1997;278:144–151. 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.
ISBN 0–87553–002–8 ❚ Hardcover ❚ 2004 $52.50 APHA Members $75.00 Nonmembers
17. National Consensus Development Panel on Effective Medical Treatment of Opiate Addiction. Effective medical treatment of opiate addiction. JAMA. 1998; 280:1936–1943.
he new 17th edition of SMEDP provides the dairy industry, associated research organizations, and the governmental bodies charged with ensuring the safety and wholesomeness of dairy products with validated methodology to ensure that harmful levels of organisms and other substances are absent and that the nutritive qualities, flavor, and appearance of products meet established specifications. An aim of SMEDP is to provide a system for the uniform testing of dairy products that will become a critical component of both government and industry analytical programs. The presentation of methods in SMEDP is designed to foster uniformity by providing sufficient information on key test procedures so that analysts have a clear set of procedures when performing each method.
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18. Standards for Health Services in Jails. Chicago, Ill: National Commission on Correctional Health Care; 1996.
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19. Federal Bureau of Prisons. Clinical Practice Guidelines: Detoxification of Chemically Dependent Persons. Washington, DC: National Institute of Corrections; 2000:1–44.
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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.
Call for Papers
Prison Health
23. Wilson DJ. Drug Use, Testing, and Treatment in Jails. Washington, DC: Bureau of Justice Statistics; 2000.
The American Journal of Public Health (AJPH), in collaboration with the Community Voices Initiative of the National Center for Primary Care, Morehouse School of Medicine, is planning a theme issue dedicated to an examination of quality of care and health disparities in America’s Criminal Justice System. Work in communities has led to examination of health disparities along race, age, and gender lines. This work has involved itself with those who live without restraint in our communities. Little systematic scientific evidence is available to permit analysis of the strengths or limitations of the prison health care system and the health status of residents of these facilities. In addition, we are now witnessing a phenomenon of large numbers of people leaving the prison system and returning to our communities, some with compromised health and most with no access to comprehensive health care services. Whether behind the fence or returning to communities, there are public health implications. The guest editors are soliciting contributions of articles for possible publication, focusing on major research issues and practice activities related to delivery of health services to this special population. All papers will undergo peer review by the AJPH’s editorial team and the guest editors. In order to be considered for inclusion in the theme issue, articles must be submitted by October 1, 2004, through the online submission at http://submit.ajph.org. This website also provides Instructions for Authors, including specific guidelines for various types of papers. When submitting articles, please select Prison Health under the Theme Issue menu. Additional information concerning the theme issue can be obtained by contacting guest editors: Henrie M. Treadwell, PhD, at
[email protected] and Joyce Nottingham, PhD, at 1524 | Research and Practice | Peer Reviewed | Fiscella et al.
American Journal of Public Health | September 2004, Vol 94, No. 9
