nonmedical prescription drug use and delinquency ...

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NONMEDICAL PRESCRIPTION DRUG USE AND DELINQUENCY: AN ANALYSIS WITH A NATIONAL SAMPLE JASON A. FORD

Ttiere is an abundance of research on the association between substance use and delinquency. However, an area yet to be examined is the association between nonmedicai prescription drug use and delinquency This is important given the substantial increase in nonmedical prescription drug use in recent years and the fact that recent national sun/eys of substance use show that the prevalence of nonmedical prescription drug use is now greater than that of illicit drugs other than marijuana. Using data from a national sample, this research examines the association between nonmedical prescription drug use and delinquency among adolescents. Findings indicate that nonmedical prescription drug use is significantly associated with self-reported delinquency and arrest However, the use of other illicit drugs is more strongly associated with self-reported delinquency and arrest than nonmedical prescription drug use. INTRODUCTION

The association between substance use and delinquency has been examined rigorously. Research on offenders, addicts, and members of the general population indicate a positive statistical association between substance use and delinquency (Dawkins, 1997; Elliott, Huizinga, & Menard, 1989; Fagan, Weis, & Cheng, 1990; Harrison & Gfroerer, 1992; Inciardi & Pottieger, 1991; Johnson, Wish, Schmeidler, & Huizinga, 1991; National Institute of Justice, 2001; Weite, Zhang, & Wieczorek, 2001; White, 1990). More recently, the association between substance use and offending behavior over the life course has been considered. Findings indicate that

Jason A. Ford, Ph.D., isanassistantprofessorof sociology atthe University of Central Florida. Dr. Ford's research focuses on substance use, antisocial behavior over the life course, and sports participation and deviance.

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substance use leads to continuity in offending (Anglin & Speckart, 1988; Chaiken & Chaiken, 1990;Dawkins, 1997; Elliott et al., 1989; Ford, 2005; Inciardi&Pottieger, 1991; White, Loeber, Stouthamer-Loeber, & Farrington, 1999), distinguishes high level chronic offenders from other more normative groups of offenders (Wiesner & Windle, 2004), makes desistance from offending behavior less likely (Schroeder, Giordano, & Cemkovich, 2007; Weite, Barnes, Hoffman, Wieczorek, & Zhang, 2005; Zhang, Weite, & Wieczorek, 2002), and is a significant predictor of recidivism (Kirkish et al., 2000; Risler, Sutphen, & Shields, 2000; Stoolmiller & Blechman, 2005; Vermeiren, de Clippele, & Deboutte, 2000). One area of the substance use/delinquency nexus that has not yet been examined is the association between nonmedical prescription drug use and delinquent behavior. Nonmedical prescription drug use is defined as use without a prescription from a doctor or solely for the feeling or experience caused by the drug (Substance Abuse and Mental Health Services Administration [SAMHSA], 2006). This gap in the literature is surprising given the dramatic increase in the prevalence of nonmedical prescription drug use in recent years (Gledhill-Hoyt, Lee, Strote, & Wechsler, 2000; Johnston, O'Malley, Bachman, & Schulenberg, 2006; Mohler-Kuo, Lee, & Wechsler, 2003; SAMHSA, 2006). In addition, national surveys of substance use now indicate that nonmedical prescription drug use is more prevalent than the use of other illicit drugs, except marijuana (Johnston et al., 2006; McCabe, Teter, & Boyd, 2006; SAMHSA, 2006). The current research fills this gap in the literature by examining the association between nonmedical prescription drug use and delinquent behavior. While a theoretical explanation for the association is not being proposed, this research still examines an important issue given the known association between substance use and delinquency and the dramatic increase in nonmedical prescription drug in recent years. Because the paper is atheoretical, only a general review of literature examining the relationship between drug use and delinquency is provided. The existing research leaves little doubt that substance use and delinquency are associated, and several hypotheses have been tested to explain the complex nature of the relationship. First, there is some evidence that substance use is a cause of delinquency. Goldstein's tripartite model states that there are three ways substance use causes delinquency, especially violent offending (Goldstein, 1985; Goldstein, Brownstein, & Ryan, 1992; Menard & Mihalic, 2001). First, the psychopharmacological effects of drugs cause users to offend. The short- and longterm effects of substance use reduce inhibitions and impair judgment, making users more prone to commit delinquent acts. Second, there is an economic compulsive element whereby substance users commit remunerative crimes in order to finance their drug habits. Third, violent crimes such as robberies and assaults are systemic to the nature of the illegal drug market. While research based on Goldstein's tripartite 494

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NONMEDICAL PRESCRIPTION DRUG USE AND DELINQUENCY

model generally examines violent offending, researchers have also used Goldstein's tripartite model as a framework to examine general offending behavior (Menard & Mihalic, 2001; Weite et al., 2005). In addition, one of the components of his model is "economic compulsive crime," and a number of studies find a positive relationship between substance use and income generating property crime (Anglin & Speckart, 1988; Ball, Shaffer, & Nurco, 1983; Chaiken & Chaiken, 1990; Inciardi, 1979; Inciardi & Pottieger, 1991; McGlothlin, Anglin, & Johnson, 1978). Second, several researchers note that delinquent behavior often precedes substance use; therefore, substance use cannot be a cause of delinquency (Anglin & Speckart, 1988; Chaiken & Chaiken, 1990; Johnston, O'Malley, & Eveland, 1978). This temporal order suggests that delinquency is likely the cause of substance use. This is possible because involvement in delinquent behavior creates the context and opportunity for substance use, primarily via peer associations. These researchers argue that substance use is a natural consequence of a delinquent lifestyle. Third, some researchers believe that the relationship between substance use and offending is dynamic over the life course (Elliott et al., 1989; Huizinga, Menard, & Elliot, 1989; Mason & Windle, 2002; Menard, Mihalic, & Huizinga, 2001). They argue that rather than a unidirectional relationship between substance use and offending, a process of mutual causation is more likely. Once both behaviors are initiated, substance use and offending appear to be reciprocally related, producing continuity in both behaviors over time. In addition, substance use is more closely associated with offending behavior in adolescence than adulthood (Menard et al., 2001), and for late-onset rather than early-onset offenders (Weite et al., 2001). Finally, many believe that the connection between substance use and delinquency is spurious. This is likely for two reasons. First, delinquency and substance use are both based on a common set of risk factors, for example low self-control (Gottfi-edson & Hirschi, 1990). Thus, a single theoretical model can explain both substance use and delinquency. Second, many believe that substance use and delinquency are so closely related that they are viewed as general forms of deviance. Problem behavior theory, for example, states that substance use and delinquency are not separate constructs; but are rather expressions of a unitary predisposition toward deviant behavior (Donovan & Jessor, 1985; Jessor, Donovan, & Costa, 1991). However, others argue that substance use and delinquency are better conceptualized as discrete factors rather than as a single construct (Dembo et al., 1992; Huizinga et al., 1989; Loeber, Farrington, Stouthamer-Loeber, & Van Kämmen, 1998; McCord, 1990; Paradise & Cauce, 2003; Windle & Barnes, 1988). They believe that modeling substance use and delinquency as a single factor likely masks reciprocal influences between the two that may emerge over time. Thus, conceptualizing substance use

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and delinquency as a single construct limits our understanding of the relationship between substance use and delinquency. To determine if nonmedical prescription drug use is associated with delinquent behavior, it is important to control for the possibility that substance use and delinquency are caused by a common set of risk factors. Therefore, social control and social learning theories are briefly discussed, and measures related with these theories are included in the analytical models. Social control theory (Hirschi, 1969) contends that a single moral order exists and that motivation for deviance is invariant across individuals. According to the theory, conformity is based on the intemalization of societal values and norms, and integration into prosocial groups. That is, a bond develops between an individual and society that deters him or her from violating rules. This social bond consists of four dimensions: attachment, commitment, involvement, and belief Attachment refers to affective ties to significant others (parents and school officials) and constrains behavior because deviance would likely harm these important social relationships. Commitment is an investment in conventional activities and goals (e.g., education) that creates a stake in conformity. Because deviant behavior jeopardizes present and future conventional aspirations, a strong commitment to conventional activities should constrain behavior. Involvement refers to the time and energy spent participating in conventional activities, which decreases opportunity for deviant behavior. Finally, belief refers to the endorsement or intemalization of societal rules and values. A number of studies indicate that adolescents with weak social bonds are more likely to engage in delinquent behavior, providing support for social control theory (Agnew, 1991a; Costello & Vowell, 1999; Hirschi, 1969; Junger & Marshall, 1997; Rankin & Kern, 1994; Wright, Avshalom, Moffitt, & Sivla, 1999). Social learning theory (Akers, 1985) is based on the assumption that everyone has the potential to be deviant and focuses on the impact of socialization and the normative influences of significant others. The theory builds on Sutherland's (1947) classic theory of differential association by incorporating elements of behavioral psychology (Skinner, 1953). The causal mechanisms that explain deviant behavior involve interactions with primary group members (i.e., family and friends) that expose individuals to deviant role models, provide normative definitions, and reinforce behavior. To predict delinquent behavior, social learning theorists often focus on the influence of friends and peers. According to social learning theory, deviant behavior occurs when it is defined as desirable and has been differentially reinforced over alternative behavior. There are four key components to social learning theory: differential association (exposure to normative/deviant definitions), imitation (behavioral modeling), definitions (attitudes and meaning people attach to behavior), and differential reinforcement (rewards/punishment for behavior). An 496



abundance of research supports social learning theory as a predictor of delinquent behavior (Agnew, 1991b; Burgess & Akers, 1966; Elliott, Huizinga, & Ageton, 1985; Matsueda & Heimer, 1987; Warr, 1993a; Warr 1993b; Warr & Stafford, 1991 ; White, Pandina, & LaGrange 1987; Winfi-ee, Backstrom, & Mays, 1994). NoNMEOiCAL PRESCRIPTION DRUG USE

There has been a substantial increase in the prevalence of non-medical prescription drug use in recent years, especially among adolescents. From 1992 to 2003 there was a 212% increase in reported nonmedical prescription drug use among adolescents ages 12 to 17 (The National Center on Addiction and Substance Abuse at Columbia University, 2005). The National Survey on Drug Use and Health (NSDUH) is one of the few ongoing national surveys that measures nonmedical prescription drug use. Findings from the 2005 survey indicate that approximately 21% of the U.S. population age 12 and older report using any type of prescription drug nonmedically in their lifetime, 16% report use of opiate-type pain killers, 8% report tranquilizer use, 8% report stimulant use, and 2% report sedative use (SAMHSA, 2006). The increasing popularity of nonmedical prescription drug use is based on the putative advantages of prescription drugs over "street" drugs: the drugs are easier to obtain, there is less likelihood of arrest, use is more socially accepted, and there is a perception that prescription drugs are safer (Cicero, Inciardi, & Munoz, 2005). Unfortunately, the empirical research on substance use has not kept pace with the increasing rate of nonmedical prescription drug use, leaving many questions unanswered. This lack of research is disconcerting considering the public health concern regarding substance use and abuse. Existing research on nonmedical prescription drug use has highlighted the misuse potential of prescription drugs (Johnston et al., 2006; Kollins, MacDonald, & Rush, 2001 ; Poulin, 2001 ; SAMHSA, 2006) and has noted the increasing number of "mentions" of prescription drugs in hospital emergency room reports (Hurwitz, 2005; SAMHSA, 2005). Furthermore, there are important limitations to the existing body of research on nonmedical prescription drug use. Of primary concern is the reliance on school-based samples (i.e.. Monitoring the Future, College Alcohol Study, and the Student Life Survey) which are not generalizable to the U.S. population. Thus, it is important for future research to examine nonmedical prescription drug use with samples that are more representative of the U.S. population (i.e.. National Survey on Drug Use and Health). Finally, only a few of the existing studies examine the nonmedical use of any prescription drug (McCabe et al., 2006; Simoni-Wastila, Ritter, & Strickler, 2004; Simoni-Wastila & Strickler, 2004). The majority of research focuses on the use of opiate-type pain killers (McCabe, Teter, & Boyd, 2005; McCabe, Teter, Boyd, SPRING 2008

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Knight, & Wechsler, 2005; Sung, Richter, Vaughan, Johnson, & Thom, 2005; Zacny et al., 2003) or stimulants (Herman-Stahl, Krebs, Kroutil, & Heller 2007; Kroutil et al., 2006; Low & Gendaszek, 2002; McCabe, Knight, Teter, & Wechsler, 2005; Teter, McCabe, Boyd, & Guthrie, 2003; Teter, McCabe, Cranford, Boyd, & Guthrie, 2005), with little research attention on prescription tranquilizers (McCabe, 2005) or sedatives (Goodwin & Hasin, 2002). A number of the existing studies examine the demographic characteristics of nonmedical prescription drug users. As with other forms of substance use, findings indicate that adolescents and young adults are at the greatest risk for non-medical prescription drug use (Johnston et al., 2006; SAMHSA, 2006). Research on the relationship between gender and nonmedical prescription drug use has produced inconclusive results. Some research finds that males report higher rates of use (Kroutil et al., 2006; McCabe, 2005; McCabe et al., 2006; McCabe, Knight et al, 2005), while others report that females are more likely to use (Simoni-Wastila et al., 2004; Simoni-Wastila & Strickler, 2004; Sung et al, 2005). Finally, the existing research overwhelmingly indicates that Whites are at greater risk for use than nonWhites (Goodwin & Hasin, 2002; Herman-Stahl et al, 2007; Kroutil et al, 2006; McCabe, 2005; McCabe et al, 2006; McCabe, Teter, & Boyd, 2005; McCabe, Teter, Boyd et al, 2005; Simoni-Wastila & Strickler, 2004; Sung et al, 2005). Beyond these basic demographic characteristics, researchers have examined additional risk factors associated with nonmedical prescription drug use. The use of marijuana and other illicit drugs are strongly associated with nonmedical prescription drug use (Herman-Stahl et al, 2007; McCabe, 2005; McCabe et al, 2006; McCabe, Teter, & Boyd, 2005; McCabe, Teter, Boyd, et al 2005; Simoni-Wastila et al, 2004; Simoni-Wastila & Strickler, 2004; Sung et al, 2005). It seems likely that nonmedical prescription drug use may simply be another form of substance use. Existing research also shows a relationship between health status and nonmedical prescription drug use. Persons who report being in fair or poor physical health (Simoni-Wastila et al, 2004; Simoni-Wastila & Strickler, 2004) and those with a history of mental health problems (Goodwin & Hasin, 2002; Herman-Stahl et al, 2007; Hser, Hoffman, Grella, & Anglin, 2001 ; Matzger & Weisner, 2007) are at an increased risk for nonmedical prescription drug use. It is possible that individuals who cannot obtain prescription drugs legally may be obtaining them via alternative means in order to treat health-related problems. Another focus of the existing research on nonmedical prescription drug use has been motives for use and sources of diversion. There is an extensive research literature on motives for substance use, as many people report using drugs as a means of obtaining positive reinforcement or as a way to avoid negative consequences (Johnston & O'Malley, 1986; Low & Gendaszek, 2002; Teter et al, 2005). Findings 498



indicate that motivations for nonmedical prescription drug use among college students include to improve intellectual performance, increase concentration/ alertness, relieve pain, experiment, and get high (Low & Gendaszek, 2002; Teter et al., 2005; McCabe, Cranford, Boyd, & Teter, 2007). Finally, research indicates that the most common source of diversion among adolescents and young adults are friends and family members (McCabe et al., 2007; SAMHSA, 2006). There is a dearth of research on the association between nonmedical prescription drug use and offending. In a study of probationers in Kentucky, Luekefeld and colleagues (2005) compare the offending behavior of OxyContin users to nonusers. The research shows that probationers who use OxyContin nonmedically have higher rates of criminal offending than probationers who do not use OxyContin. In addition, two studies include arrest history as a predictor of nonmedical prescription drug use in regression models. Arrest is not a significant predictor of either stimulant use (Herman-Stahl et al., 2007) or opioid use (Sung et al., 2005) in these studies. Given the vast literature on the connection between substance use and delinquency, it is surprising that little research exists on the relationship between nonmedical prescription drug use and delinquency. There is a long history of research on the relationship between substance use and delinquent behavior; however, research has not yet established if nonmedical prescription drug use is associated with delinquent behavior. Therefore, the goal of this research is to determine if nonmedical prescription drug use is significantly associated with juvenile delinquency. The current research is important for a number of reasons. First, there has been a considerable increase in nonmedical prescription drug use in recent years, and research indicates that adolescents and young adults are more likely to report nonmedical prescription drug use than the use of illicit dmgs, not including marijuana. While we are starting to better understand nonmedical prescription drug use, clearly more research is needed to identify risk factors and consequences of use, including delinquency. Second, research must determine if nonmedical prescription dmg use is simply another form of substance use or if the use of prescription dmgs is different than the use of traditional "street" dmgs. METHODS

The data for this study are the 2005 National Survey on Dmg Use and Health (NSDUH), which is an ongoing household survey of individuals ages 12 and older in the U.S. (U.S. Department of Health and Human Services, 2006). The primary goal of the NSDUH, formerly known as the National Household Survey on Dmg Abuse, is to measure the prevalence and correlates of substance use in the U.S. The survey also includes a set of questions that measure youth experiences that make it particularly suitable for this study. The sample universe consists of the civilian. SPRING 2008

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noninstitutionalized population of the U.S. ages 12 and older. A multistage area probability sample for all 50 states and the District of Columbia was used to collect data from a sample of 68,308 persons. However, the public use data file used in this study contains data from only 55,905 respondents. This reduction in sample size is due to a subsampling step used in the disclosure protection procedures, to control for the risk of disclosing the identity of any respondent (U.S. Department of Health and Human Services, 2006). There are two dependent variables used in this analysis, a weighted scale of juvenile delinquency and a measure of self-reported arrest, both items measure behavior in the 12 months prior to the survey. For the weighted delinquency measure, scale items include fighting with parents, got into a serious fight at school/work, taken part in fight where group fights group, carried a handgun, sold illegal drugs, stolen or tried to steal anything worth more than $50, and attacked someone with the intent to seriously hurt them. Responses are coded from 0 (0 times) to 4 (10 or more times). Each scale item is assigned a ratio-score seriousness weight derived from the National Survey of Crime Severity (Bureau of Justice Statistics, 1985). This scale is weighted in an effort to avoid the impact that high levels of involvement in less serious offenses would have in the calculation of a total delinquency involvement score. Therefore, this scale is constructed to recognize the importance of both frequency and seriousness of delinquency. The measure of self-reported arrest is dichotomous, indicating the incidence ofan arrest in the past 12 months. The independent variable of interest for this study is nonmedical prescription drug use in the past year. The NSDUH defines nonmedical use as use without a prescription from a doctor or solely for the feeling or experience caused by the drug. This analysis examines the nonmedical use of any prescription drug, which includes the use of pain relievers (e.g., Darvocet, Percocet, Vicodin, codeine, and Demerol), tranquilizers (e.g., Klonopin, Xanax, Ativan, Valium, and Librium), stimulants (e.g., Ritalin, Cylert, Dexedrine, and Adderall), and/or sedatives (e.g., phénobarbital, Seconal, and Restoril). A number of demographic controls are included in the analysis. These controls include age (12-17), gender (0 = female, 1 = male), race (0 = White, 1 = non-White), total family income (0 = $20,000 or more, 1 = less than $20,000), and population density (0 = respondent did not live in a Core Based Statistical Area (CBSA) or respondent lived in a CBSA with less than one million persons, 1 = respondent lived in a CBSA with more than one million persons). The use of alcohol and other illicit drugs, not including marijuana, are also included as controls (0 = no, 1 = yes). Alcohol use is defined as binge drinking, that is, five or more drinks on the same occasion on at least one day in the past 30 days. A respondent is coded as an other

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illicit drug user if he or she reported the use of cocaine, crack, heroin, LSD, PCP, hallucinogens, inhalants, ecstasy, and/or methamphetamines. Common theoretical predictors of juvenile delinquency, social control, and social leaming, are also included in the multivariate models. Two scales measure social bonding according to social control theory. A school bond scale (alpha = .694) consists of five items: like going to school, school work is meaningful, things leamed at school are important, classes are interesting, teachers tell you that you are doing good work. A parental bond scale (alpha = .913) consists of seven items: parents check if you have done homework, parents help you with homework, parents make you do chores, parents limit the amount of TV you watch, parents limit the amount of time you went out with friends on a school night, parents let you know that you are doing a good job, and parents tell you they are proud of something you have done. The items that are used to create both bonding scales have likert-type response sets ranging from 1 (weak bond) to 5 (strong bond). Two scales measure the influence of peers, an important predictor according to social leaming. The NSDUH has no items asking respondents about the delinquent involvement of their peers, so the peer items used in the analysis are based on substance use. A scale is created to measure peer substance use (alpha = .853). Items in this scale ask respondents how many of the students at their school smoke cigarettes, use marijuana, drink alcohol, and get drunk weekly. The response set for these questions range from 1 (none) to 5 (all). Finally, a scale is created to measure friends' attitudes toward drug use (alpha = .903). Respondents are asked how their close friends would feel about smoking one pack of cigarettes daily, trying marijuana, using marijuana monthly, and having one or two drinks of alcohol a day. The response set ranges from 1 (strongly disapprove) to 3 (neither approve/disapprove). ANALYTIC STRATEGY

Two separate sets of regression models are estimated to examine the relationship between delinquent behavior and nonmedical prescription drug use. First, OLS regression models are estimated with the weighted delinquency scale as the dependent variable. Second, logistic regression models are estimated with the selfreported measure of arrest as the dependent variable. Models are estimated for the nonmedical use of any prescription drug and for each class of prescription drug (pain relievers, tranquilizers, stimulants, and sedatives). Both sets of regression models include controls for demographic characteristics (age, gender, race, family income, and population density), measures of binge drinking and illicit drug use, and variables related with social control and social leaming theories. In order to take into account the complex multistage sampling design of the NSDUH, analyses are conducted using the SVYSET and SVY commands in STATA. These commands SPRING 2008

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allow STATA to consider survey design effects, including stratification and weight variables and the primary sampling unit, when estimating test statistics. FINDINGS

Descriptive statistics for all variables are shown in Table 1. Limiting the analysis to respondents between the ages of 12 and 17 reduces the sample size to roughly 17,000 respondents. The mean age is 14.53, there are roughly an equal number of boys and girls, and just over one third of the sample is non-White. The mean score for the weighted delinquency measure is 8.39, and about 8% of the sample report being arrested. Finally, nearly 9% of the sample reports the nonmedical use of any prescription drug during the past year. This is slightly higher than the prevalence of respondents who report using any illicit drug other than marijuana (8%) during the same time period. Concerning the individual classes of prescription drugs, 7% of the sample report the nonmedical use of pain relieving prescription drugs, about

TABLE 1 DESCRIPTIVE STATISTICS

Measure

Range

Mean (%)

Standard Deviation

Weighted juvenile delinquency scale Self-reported arrest

0-174 0-1

8.392 0.084 (8.4%)

13.990 0.278

Past year nonmedical prescription drug use Any Pain relievers Tranquilizers Stimulants Sedatives

0-1 0-1 0-1 0-1 0-1

0.088 (8.8%) 0.074 (7.4%) 0.020(2.0%) 0.021 (2.1%) 0.005 (0.5%)

0.284 0.262 0.141 0.144 0.070

Controls Age Gender (male) Race (non-White) Family income (