AJPH RESEARCH

Health Disparities in Drug- and Alcohol-Use

Disorders: A 12-Year Longitudinal Study
of Youths After Detention
Leah J. Welty, PhD, Anna J. Harrison, MS, Karen M. Abram, PhD, Nichole D. Olson, PhD, David A. Aaby, MS, Kathleen P. McCoy, PhD,
Jason J. Washburn, PhD, and Linda A. Teplin, PhD

Objectives. To examine sex and racial/ethnic differences in the prevalence of 9 challenges attaining adult social roles,17 such
substance-use disorders (SUDs)—alcohol, marijuana, cocaine, hallucinogen or PCP, opiate, as establishing stable careers18 and families19;
amphetamine, inhalant, sedative, and unspecified drug— in youths during the 12 years continued substance abuse further compro-
after detention. mises their futures.
Despite its importance, few longitudinal
Methods. We used data from the Northwestern Juvenile Project, a prospective longi-
studies of delinquent youths have examined
tudinal study of 1829 youths randomly sampled from detention in Chicago, Illinois, starting
the prevalence of substance abuse during
in 1995 and reinterviewed up to 9 times in the community or correctional facilities through
young adulthood. We searched the literature
2011. Independent interviewers assessed SUDs with Diagnostic Interview Schedule for for prospective longitudinal studies of youths
Children 2.3 (baseline) and Diagnostic Interview Schedule version IV (follow-ups). in the juvenile justice system conducted since
Results. By median age 28 years, 91.3% of males and 78.5% of females had ever had 1990 that met the following criteria: (1) fol-
an SUD. At most follow-ups, males had greater odds of alcohol- and marijuana-use disorders. lowed youths during young adulthood (‡ 21
Drug-use disorders were most prevalent among non-Hispanic Whites, followed by His- years) and (2) measured alcohol or drug use or
panics, then African Americans (e.g., compared with African Americans, non-Hispanic Whites disorder. Only 3 studies met these criteria
had 32.1 times the odds of cocaine-use disorder [95% confidence interval = 13.8, 74.7]). (summary table available from authors).16,20–22
Conclusions. After detention, SUDs differed markedly by sex, race/ethnicity, and These studies found that substance abuse
substance abused, and, contrary to stereotypes, did not disproportionately affect remained prevalent as youths aged.
Although these previous investigations
African Americans. Services to treat substance abuse—during incarceration and
provide important information, they have
after release—would reach many people in need, and address health disparities in
limitations. Ramchand et al. examined only
a highly vulnerable population. (Am J Public Health. 2016;106:872–880. doi:
symptoms of dependence, not diagnoses.20
10.2105/AJPH.2015.303032) Diagnoses provide a more systematic, con-
sensually understood, and clinically mean-
ingful description of the frequency, severity,

T he Department of Justice estimates that,

among males born in 2001, 1 in 3 African
Americans and 1 in 6 Hispanics will be in-
After detention, SUDs present a continu-
ing challenge for the community mental
health system. Most stays in detention are
and recency of symptoms.23–26 Moreover,
this study oversampled offenders referred for
substance abuse treatment, thus biasing the
carcerated at some point during their lifetime, brief (median, 15 days),15 and when detained sample.20 Chitsabesan et al. sampled fewer
compared with 1 in 17 non-Hispanic Whites.1 youths return to their communities, a sub- than 100 participants and had nearly 50%
Racial/ethnic minorities are disproportion- stantial proportion may need treatment of attrition; this study was conducted in the
ately incarcerated, especially for drug crimes.2–4 SUDs as they age.16 Delinquent youths face United Kingdom, limiting generalizability to
More than 2.4 million youths and adults are
currently incarcerated in the United States.5–7
Every year, there are nearly 1.4 million arrests ABOUT THE AUTHORS
of juveniles; more than 250 000 cases result in Linda A. Teplin, Anna J. Harrison, Karen M. Abram, Nichole D. Olson, David A. Aaby, and Kathleen P. McCoy are with
Health Disparities and Public Policy, Department of Psychiatry and Behavioral Sciences, Northwestern University Feinberg
detention.8 Substance abuse is a significant School of Medicine, Chicago, IL. Leah J. Welty is with Department of Preventive Medicine and Health Disparities and Public
problem among youths in the juvenile justice Policy, Department of Psychiatry and Behavioral Sciences, Northwestern University Feinberg School of Medicine. Jason J.
system.9,10 More than 90% report having Washburn is with Department of Psychiatry and Behavioral Sciences, Northwestern University Feinberg School of Medicine,
and Alexian Brothers Behavioral Health Hospital, Hoffman Estates, IL.
used illicit drugs.11 Irrespective of sex or race/ Correspondence should be sent to Linda A. Teplin, Owen L. Coon Professor, Vice Chair of Research, Director, Health Disparities
ethnicity, substance-use disorders (SUDs) are and Public Policy, Department of Psychiatry and Behavioral Sciences, Feinberg School of Medicine, Northwestern University, 710 N
the most common psychiatric disorders among Lakeshore Dr, #900, Chicago, IL 60611 (e-mail: [email protected]). Reprints can be ordered at http://www.
ajph.org by clicking the “Reprints” link.
delinquent youths: 49% to 76%12,13 of males This article was accepted December 7, 2015.
and 34% to 77%12–14 of females have an SUD. doi: 10.2105/AJPH.2015.303032

872 Research Peer Reviewed Teplin et al. AJPH May 2016, Vol 106, No. 5
 AJPH RESEARCH

the United States.22 Teplin et al. examined Sample and Procedures generates diagnoses for alcohol-, marijuana-,
youths only up to a median age of 20 We recruited a stratified random sample of and “other” illicit drug–use disorders (e.g.,
years.16,21 Most important, all 3 studies 1829 youths at intake to the Cook County “hard drugs” such as cocaine, opiates, hallu-
combined drugs with dramatically different Juvenile Temporary Detention Center in cinogens or PCP) for the past 6 months. We
etiologies and consequences—for instance, Chicago, Illinois, between November 20, derived diagnoses for specific “other” illicit
marijuana (now legal in some states27–33) and 1995, and June 14, 1998, who were awaiting drug use–disorders the same way the DISC 2.3
“hard drugs” (e.g., cocaine, hallucinogens or the adjudication or disposition of their case. scores alcohol- and marijuana-use disorders.
PCP [phencyclidine], opiates). This approach The Cook County Juvenile Temporary Follow-up interviews. For follow-up in-
obfuscates important differences: substances Detention Center is used for pretrial deten- terviews, we administered the Diagnostic
vary widely in their immediate and long-term tion and for offenders sentenced for less than Interview Schedule, version IV (DIS-IV)53,54
effects on brain chemistry,34–38 effects on 30 days. To ensure adequate representation of because the DISC was not sufficiently
health (such as risk for HIV, fatal overdose, key subgroups, we stratified our sample by comprehensive to cover the substance use
drug-induced psychosis, myocardial infarc- sex, race/ethnicity (African American, non- behaviors of aging delinquent youths.
tion, liver disease, neurotoxic effects, and Hispanic White, Hispanic, other), age (10 to The DIS-IV assesses SUDs in the year before
pancreatitis),39–43 and social consequences 13 years or ‡ 14 years), and legal status the interview for alcohol, marijuana, and
(e.g., unemployment44 and risk for adolescent (processed in juvenile or adult court). The the following specific “other” illicit drugs:
pregnancy45). sample included 1172 males and 657 females; amphetamines, sedatives, cocaine, opiates, hal-
We addressed the limits of previous in- 1005 African Americans, 296 non-Hispanic lucinogens or PCP, inhalants, and unspecified
vestigations. To our knowledge, this is the Whites, 524 Hispanics, and 4 other race/ drugs. As in our earlier work,16 we checked
first comprehensive epidemiological study of ethnicity; mean age, 14.9 years (Table A, that changes in prevalence over time were not
SUDs in delinquent youths during young available as a supplement to the online version attributable to changes in measurement. To
adulthood (up to median age 28 years). We of this article at http://www.ajph.org). Face- facilitate comparison with other large-scale
used data from the Northwestern Juvenile to-face structured interviews were conducted epidemiological studies of SUDs,55–58 we
Project to assess 9 SUDs: alcohol, marijuana, at the detention center in a private area, most report both lifetime and past-year prevalence.
cocaine, hallucinogen or PCP, opiate, am- within 2 days of intake.
phetamine, inhalant, sedative, and unspeci- We conducted follow-up interviews (1) at
fied drug. Focusing on sex and racial/ethnic 3, 4.5, 6, 8, and 12 years after baseline for the Statistical Analysis
differences, we used multiple follow-up in- entire sample; (2) at 3.5 and 4 years after We conducted all analyses with com-
terviews to examine (1) lifetime prevalence of baseline for a random subsample of 997 mercial software (Stata version 12; Stata Corp
SUDs and (2) changes in the past-year participants (600 males and 397 females); and LP, College Station, TX) with its survey
prevalence of SUDs during the 12 years (3) at 10 and 11 years after baseline for the last routines. To generate prevalence estimates
after youths leave detention. The sample is 800 participants enrolled at baseline (460 and inferential statistics that reflect Cook
large (n = 1829), includes males (n = 1172) males and 340 females). Participants were County Juvenile Temporary Detention
and females (n = 657), and is racially/ interviewed whether they lived in the Center’s population, we assigned each par-
ethnically diverse. community or in correctional facilities. In- ticipant a sampling weight augmented with
This study is timely, providing data needed terviews were conducted through 2011. a nonresponse adjustment to account for
to address health disparities. Hispanics are Participants signed either an assent form missing data.59 We used Taylor series line-
especially important to study because they are (if they were aged < 18 years) or a consent arization to estimate standard errors.60,61
now the largest ethnic minority in the United form (if they were aged ‡ 18 years). The Because some participants were inter-
States, constituting 16.3% of the pop- Northwestern University institutional review viewed more often than others, we summa-
ulation.46 Together, African Americans and board and the Centers for Disease Control rize prevalence at 6 time points for the entire
Hispanics constitute more than one third of and Prevention institutional review board sample: baseline (time 0) and time 1 through
young adults in the general population47 but approved all study procedures and waived time 5, corresponding to approximately 3, 5,
approximately two thirds of persons in- parental consent for persons younger than 6, 8, and 12 years after baseline. Table A
carcerated in juvenile7 and adult facilities.48 18 years, consistent with federal regulations summarizes sample demographics and re-
regarding research with minimal risk.23 tention, and shows that 83% of participants
had a time-5 interview. Race/ethnicity
(African American, Hispanic, non-Hispanic
Measures White, other) was self-identified.
METHODS Baseline. We administered the Diagnostic We used logistic regression to examine
The most relevant information is sum- Interview Schedule for Children, version 2.3 sex and racial/ethnic differences in lifetime
marized here. Additional detail is in the (DISC 2.3),51,52 based on the Diagnostic and prevalence 12 years after baseline.
“eMethods,” available as a supplement to the Statistical Manual of Mental Disorders, Revised Changes in prevalence over time. We used all
online version of this article at http://www. Third Edition (DSM-III-R), the most recent available interviews, with an average of 7
ajph.org, and is published elsewhere.12,16,49,50 version available at the time. The DISC 2.3 interviews per person (range = 1–10

May 2016, Vol 106, No. 5 AJPH Teplin et al. Peer Reviewed Research 873
AJPH RESEARCH

interviews per person). We used generalized (Table 1). Compared with females, males had respectively. Additional figures are provided in
estimating equations62 to fit marginal models higher lifetime prevalence of any SUD and its Figures A through N, available as supplements to
examining (1) differences in the prevalence of subcategories alcohol-use disorder, any the online version of this article at http://www.
SUDs by sex and race/ethnicity over time and drug-use disorder, and marijuana-use disor- ajph.org. Tables D through H (available as sup-
(2) changes in the prevalence of disorders over der. By contrast, females had higher lifetime plements to the online version of this article at
time. Unless otherwise noted, odds ratios prevalence of cocaine-, opiate-, amphetamine-, http://www.ajph.org) provide specific preva-
contrast sex and race/ethnicity over time. and sedative-use disorder. Lifetime preva- lence estimates for all disorders. We describe
All generalized estimating equation lence of “other” illicit drug–use disorder and findings by type of disorder.
models included covariates for sex, race/ its subcategories—cocaine, opiate, amphet-
ethnicity (African American, Hispanic, or amine, and hallucinogen or PCP (males only)
non-Hispanic White), aging (time since —were significantly higher among non- Any SUD, Alcohol-Use Disorder, and
baseline), age at baseline (10–18 years), and Hispanic Whites, followed by Hispanics, then Any Drug-Use Disorder
legal status at detention. We excluded the 4 African Americans (Tables B and C, available Although prevalence decreased, 12 years
participants who identified as “other” race/ as supplements to the online version of this after baseline nearly 1 in 5 participants had an
ethnicity. We modeled time since baseline article at http://www.ajph.org). Among fe- SUD and more than 1 in 10 had a drug-use
with restricted cubic splines. When main males, minorities had lower lifetime preva- disorder. The rate of decrease depended on sex
effects were significant, we estimated models lence of alcohol-use disorder. Sex and racial/ (Table I, available as a supplement to the online
with the corresponding interaction terms. We ethnic differences remained even when we version of this article at http://www.ajph.org).
included only statistically significant in- excluded participants who had been in- Sex differences. There were no significant
teraction terms in final models. For models carcerated during the entire follow-up period sex differences at baseline. After baseline,
with significant interactions between sex and (tables available from authors). however, males had higher prevalence of SUDs
aging, we report model-based odds ratios for than females (Figure A). For example, 5 years
sex differences at 3, 5, 8, and 12 years after after baseline, males had 2.34 times the odds of
baseline. There were no significant in- Prevalence of Past-Year Disorders alcohol-use disorder compared with females
teractions between sex and race/ethnicity; for Over Time (95% CI = 1.76, 3.13). Sex differences were
the interested reader, however, we provide Figure 1 illustrates racial/ethnic differences largest in the first half of the follow-up period.
prevalence estimates for specific subgroups in over time for any SUD. Figures 2, 3, and 4 Racial/ethnic differences. Throughout the
the tables available as supplements to the illustrate the differences for alcohol-, follow-up period, non-Hispanic Whites were
online version of this article at http://www. marijuana-, and cocaine-use disorders, significantly more likely than minorities to
ajph.org. Because incarceration may restrict
access to substances, all models included
covariates for time incarcerated before each TABLE 1—Lifetime Prevalence of Substance-Use Disorders by Sex From the Baseline
interview. We estimated all generalized es- Interview (1995–1998) Through Time 5 (12 Years Later): Cook County, Chicago, IL
timating equation models with sampling
weights to account for study design. Prevalence, % (SE)
Male vs Female,
Missing data. Although attrition was Disorder Total Male Female OR (95% CI)
modest (Table A), and we augmented sam- Any substance–use disorder 90.4 (1.3) 91.3 (1.4) 78.5 (1.7) 2.9 (2.0, 4.2)
pling weights with nonresponse adjustments, Alcohol-use disorder 77.4 (1.9) 78.6 (2.0) 62.4 (2.0) 2.2 (1.7, 2.9)
we used multiple imputation by chained
Any drug–use disorder 85.1 (1.6) 86.2 (1.7) 71.0 (1.8) 2.5 (1.8, 3.5)
equations63–65 to examine the sensitivity of
our findings to unplanned missing data. We Marijuana-use disorder 83.4 (1.6) 84.5 (1.8) 68.3 (1.9) 2.5 (1.9, 3.5)
imputed data under the assumption that Other illicit drug–use disorder 22.5 (1.6) 22.2 (1.8) 25.3 (2.0) 0.8 (0.6, 1.1)
participants who dropped out had up to twice Cocaine 10.9 (0.9) 10.5 (0.9) 16.6 (1.9) 0.6 (0.4, 0.8)
the odds of disorder compared with partici- Hallucinogen or PCP 11.3 (1.2) 11.3 (1.3) 11.6 (1.9) 1.0 (0.6, 1.5)
pants who remained in the study.66,67 Because Opiate 3.6 (0.6) 3.4 (0.6) 5.8 (0.8) 0.6 (0.4, 0.9)
there were no substantive differences in Amphetamine 1.3 (0.2) 1.1 (0.2) 3.5 (0.6) 0.3 (0.2, 0.5)
findings (tables available from authors), we Inhalant 0.5 (0.1) 0.4 (0.1) 1.0 (0.3) 0.4 (0.2, 1.02)
present results with the original data. Sedative 1.1 (0.2) 0.8 (0.2) 5.0 (1.8) 0.2 (0.1, 0.4)
Unspecified druga 9.3 (1.3) 9.4 (1.4) 7.9 (1.0) 1.2 (0.8, 1.9)

Note. CI = confidence interval; OR = odds ratio; PCP = phencyclidine. Descriptive statistics are weighted
to adjust for sampling design and to reflect the demographic characteristics of the Cook County Juvenile
RESULTS Temporary Detention Center. All substance-use disorders are measured without impairment. At
baseline, the sample included 1172 males and 657 females. At time 5, the sample included 943 males
Twelve years after baseline (median and 576 females.
age = 28 years), more than 90% of males and a
Includes other drugs not listed (e.g., betel nut, nitrous oxide, amyl nitrate [poppers], and ecstasy). Not
nearly 80% of females had a lifetime SUD assessed at baseline.

874 Research Peer Reviewed Teplin et al. AJPH May 2016, Vol 106, No. 5
 AJPH RESEARCH

70 and its subcategory, any drug–use disorder,

Prevalence of Substance-Use Disorder, %

Non−Hispanic White (n = 296)

compared with African Americans.
Hispanic (n = 524)
60 African American (n = 1005)

Marijuana-Use Disorder
50
Prevalence of marijuana-use disorder de-
creased over time, but the rate of decrease
40
depended on sex (Figure E and Table I).
Sex differences. There were no significant
30
sex differences at baseline or 12 years later. In
the interim, however, males had significantly
20
higher prevalence than females. For example,
5 years after baseline, prevalence was 22.1%
10
among males and 13.5% among females
(adjusted odds ratio [AOR] = 2.51; 95%
0
CI = 1.93, 3.26).
Baseline 3 5 6 8 12
Racial/ethnic differences. Non-Hispanic
Years From Baseline
Whites had greater odds of marijuana-use
Note. Adjusted odds ratios (95% confidence intervals) for racial/ethnic differences over time were 1.9 (1.5, 2.3) disorder compared with African Americans.
for non-Hispanic White vs African American, 1.4 (1.1, 1.7) for non-Hispanic White vs Hispanic, and 1.4 (1.1, 1.7) for
Hispanic vs African American.
“Other” Illicit Drug–Use Disorder
FIGURE 1—Prevalence of Substance-Use Disorder by Race/Ethnicity From Baseline (1995– “Other” illicit drug–use disorder includes
1998, at Detention) Through Time 5 (12 Years Later): Cook County, Chicago, IL
“hard drugs,” such as cocaine-, hallucinogen or
PCP-, opiate-, amphetamine-, sedative-, and
unspecified drug–use disorder. Overall, prev-
have any SUD and its subcategories, had any SUD compared with about a quarter alence did not decrease over time, and there
alcohol-use disorder and any drug–use dis- of African Americans and nearly a third of were no significant sex differences (Table J,
order (Table I). For example, 8 years after Hispanics (Table E). Moreover, Hispanics had available as a supplement to the online version
baseline, nearly half of non-Hispanic Whites significantly higher prevalence of any SUD of this article at http://www.ajph.org).
Racial/ethnic differences. African Americans
had the lowest prevalence of “other” illicit
drug–use disorder, followed by Hispanics,
60
then non-Hispanic Whites (Tables E through
Prevalence of Alcohol-Use Disorder, %

Non−Hispanic White (n = 296)

Hispanic (n = 524)
G). For example, 5 years after baseline,
50 African American (n = 1005) prevalence was 1.7% (African Americans),
7.1% (Hispanics), and 20.0% (non-Hispanic
40 Whites). At this time point, non-Hispanic
Whites had more than 19 times and Hispanics
had more than 8 times the odds of “other”
30
illicit drug–use disorder compared with
African Americans (Table J). However, preva-
20 lence increased over time among African
Americans (e.g., 8 years after baseline, 2.6%;
10 AOR = 1.16 per year; 95% CI = 1.14, 1.28).

0 Subcategories of “Other” Illicit

Baseline 3 5 6 8 12 Drug–Use Disorder
Years From Baseline Prevalence of hallucinogen or PCP–use
disorder and amphetamine-use disorder de-
Note. Adjusted odds ratios (95% confidence intervals) for racial/ethnic differences over time were 1.7 (1.4, 2.2)
for non-Hispanic White vs African American, 1.4 (1.1, 1.8) for non-Hispanic White vs Hispanic, and 1.2 (0.96, 1.5) creased; opiate-use disorder and unspecified
for Hispanic vs African American. drug–use disorder increased. Table K (avail-
able as a supplement to the online version of
FIGURE 2—Prevalence of Alcohol-Use Disorder by Race/Ethnicity From Baseline (1995–1998, this article at http://www.ajph.org) shows
at Detention) Through Time 5 (12 Years Later): Cook County, Chicago, IL
AORs describing sex and racial/ethnic

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AJPH RESEARCH

60 disorder (Figure 4), 18 times the odds of

Prevalence of Marijuana-Use Disorder, %

Non−Hispanic White (n = 296)

Hispanic (n = 524)
hallucinogen or PCP–use disorder, and
50 African American (n = 1005) 50 times the odds of opiate-use disorder
(Table K). Hispanics had more than 20 times
the odds of cocaine-use disorder, and more
40 than 7 times the odds of hallucinogen or
PCP–use disorder and opiate-use disorder
30 compared with African Americans.

20 Substance-Use Disorders Among

Participants in the Community
10 Because substance use is restricted in jails
and prisons, we examined SUDs only among
participants who had lived in the community
0
Baseline 3 5 6 8 12 the entire year before their 12-year interview.
Years From Baseline This subgroup consisted of 434 males and 480
females. The racial/ethnic distribution was 499
Note. Adjusted odds ratios (95% confidence intervals) for racial/ethnic differences over time were 1.3 (1.02, 1.6) African Americans, 239 Hispanics, 174 non-
for non-Hispanic White vs African American, 1.05 (0.8, 1.3) for non-Hispanic White vs Hispanic, and 1.2 (0.96, 1.5) Hispanic Whites, and 2 “other” race/ethnicity.
for Hispanic vs African American.
Tables L, M, and N (available as supple-
FIGURE 3—Prevalence of Marijuana-Use Disorder by Race/Ethnicity From Baseline (1995– ments to the online version of this article at
1998, at Detention) Through Time 5 (12 Years Later): Cook County, Chicago, IL http://www.ajph.org) show prevalence es-
timates and demographic differences at time 5
(12 years after baseline) for all SUDs. Prev-
differences. Figure 4 and Figures I through N Racial/ethnic differences. Throughout the
alence estimates and demographic differences
illustrate these differences for cocaine, opiate, follow-up, prevalence was highest among
for the subgroup were substantially similar to
and hallucinogen or PCP. non-Hispanic Whites, followed by Hispanics
those for the overall sample.
Sex differences. Females had significantly then African Americans. Compared with
higher odds of opiate-, amphetamine-, and African Americans, non-Hispanic Whites had
sedative-use disorder. more than 30 times the odds of cocaine-use

DISCUSSION
20
Non−Hispanic White (n = 296) To our knowledge, this is the first study of
Prevalence of Cocaine-Use Disorder, %

Hispanic (n = 524) delinquent youths to document that SUDs

African American (n = 1005)
during young adulthood differ markedly by
15 sex, race/ethnicity, and substance abused.
Drug-use disorders such as cocaine, halluci-
nogen or PCP, opiate, amphetamine, and
sedatives were rare among African Americans,
10 but prevalent among non-Hispanic Whites.
Marijuana-use disorder was the most prevalent
SUD during most of young adulthood, and
5 more common among males than females.
However, 12 years after baseline, alcohol-use
disorder surpassed marijuana-use disorder.
Prevalence of SUDs dropped from about
0 50% at baseline (median age = 15 years) to
Baseline 3 5 6 8 12 nearly 20% 12 years later (median age = 28
Years From Baseline years) among males and females. Similar to
other delinquent behaviors, prevalence
Note. Adjusted odds ratios (95% confidence intervals) for racial/ethnic differences over time were 32.1 (13.8,
74.7) for non-Hispanic White vs African American, 1.5 (1.04, 2.2) for non-Hispanic White vs Hispanic, and 21.2 (9.0, among females declined more rapidly than
50.1) for Hispanic vs African American. among males. This difference may be because
delinquent females are more likely than de-
FIGURE 4—Prevalence of Cocaine-Use Disorder by Race/Ethnicity From Baseline (1995–1998, linquent males to receive services,68 which
at Detention) Through Time 5 (12 Years Later): Cook County, Chicago, IL
may hasten recovery. Moreover, males are

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 AJPH RESEARCH

incarcerated more frequently and for longer generalizable to other parts of the country. Americans, than for non-Hispanic Whites.
periods of time than females, thus decreasing We had too few participants of “other” race/ Poor people, who are disproportionately
their ability to build a stable life and positive ethnicity to generalize to racial/ethnic groups racial/ethnic minorities, may be less able to
connection in the community.17,69 Despite such as Asian American or Native American. afford treatment and, if arrested, less able to
the decrease over time, prevalence of Findings do not take into account mental obtain effective legal counsel than persons of
drug-use disorders is still higher than in health or substance abuse services. Although greater means. Specialized drug courts have
the general population.55,56,70 recent studies find few differences in results the potential to divert persons to treatment,
We found striking racial/ethnic differ- between DSM-IV and DSM-V criteria,78,79 avoiding incarceration and associated
ences. Contrary to popular stereotypes of prevalence estimates might have been consequences.90–92
African Americans,71,72 prevalence of somewhat different had we used DSM-V. We Second, improve the breadth and quality
drug-use disorders such as cocaine and hal- did not examine comorbid psychiatric dis- of preventive interventions, services during
lucinogen or PCP was lowest among African orders, or the age at onset of SUD relative to correctional stays, and care after prisoners are
Americans, followed by Hispanics, then comorbid disorders. Despite these limitations, released. To date, insufficient services have
non-Hispanic Whites. For example, non- our findings have implications for future re- been available to treat substance abuse. For
Hispanic Whites had more than 30 times the search and public health policy. example, about half of youths in detention93
odds of having cocaine-use disorder than and nearly 80%94 of adults in prison do not
African Americans. These racial/ethnic dif- receive needed treatment of drug abuse.94–96
Directions for Future Research
ferences persisted even after we controlled for Although prisoners continue to be ineligible
First, investigate incarcerated persons
the additional time that African Americans for Medicaid while serving time,97 the Patient
after release. Incarcerated populations have
spend in correctional facilities, where access to Protection and Affordable Care Act97 ex-
among the highest lifetime prevalence of
substances is restricted. Our findings add to pands services after release: it mandates equal
SUDs.12,80,81 Yet nearly all large-scale epi-
the growing debate about how the “War on coverage for SUD treatment, including it as
demiological studies of SUDs exclude
Drugs” has disproportionately affected Afri- an “essential health benefit,”97 which must be
them.16,82 Ironically, we know least about the
can American youths and young adults.73–75 provided by Medicaid and the insurance
people who are at the greatest risk for the
Recent investigations have found that al- exchanges. Parity increases treatment pro-
consequences of SUDs. Studies of US pop-
though African American adolescents are no vision for SUDs.98 Moreover, of people re-
ulations are especially needed because it has
more likely than non-Hispanic Whites to use leased from jails, 25% to 30% could enroll in
the highest incarceration rate in the world83:
or sell drugs, they are more likely be arrested Medicaid in states that expanded Medicaid,
707 inmates per 100 000 residents, compared
on drug-related charges.76,77 and about 20% could enroll in a marketplace
with 118 in Canada, 148 in England and
Lifetime SUDs were the rule, not the insurance plan.99
Wales, and 470 in Russia.
exception. By median age 28 years, more than Despite these improvements, service
Second, examine how patterns of in-
90% of males and nearly 80% of females had 1 provision will continue to challenge the field
carceration affect substance abuse. Drug abuse
or more SUDs—rates substantially higher for several reasons:
and involvement in the drug economy often
than in the general population—irrespective
lead to arrest and incarceration. Incarceration
of sex or race/ethnicity. (Comparative ana- 1. Prisoners are dependent on services
may also exacerbate risk factors for substance
lyses of estimates obtained from the National provided by their facility.99 Evidence-
abuse—for example, increasing depression,84
Epidemiologic Survey on Alcohol and Re- based treatment of mental disorders and
interrupting education,85 disrupting intimate
lated Conditions [NESARC], for those aged substance abuse is critical. Yet, availability
relationships,86,87 and increasing deviant peer
25–30 years, are available from the authors.) and quality of services vary.99
associations.88,89 Yet, to our knowledge, no
The magnitude of difference, however, is 2. Substance use disorders are often comorbid
large-scale study has examined how patterns
notable. For example, two thirds of African with other psychiatric disorders, particu-
of incarceration—number and duration of
American females had lifetime marijuana-use larly among youths in the juvenile justice
incarcerations, age when incarcerated, and
disorder compared with less than 10% of those system.21,49 Accurate diagnosis of comor-
experiences during parole and probation—
in the NESARC; more than 85% of non- bid conditions requires systematic assess-
affect the development, persistence, de-
Hispanic White males had lifetime marijuana-use ment of both mental health and substance
sistance, and recurrence of SUDs. Prospective
disorder compared with less than one fifth use problems.100,101 Traditional treatments
studies are essential to address these public
in the NESARC. A quarter of Hispanic fe- are less effective for persons with
health concerns.
males had ever had a hallucinogen or PCP– comorbid disorders. Integrated treatment
use disorder compared with about 2% in the approaches are preferable, but not widely
general population. Implications for Public Policy available.102
First, address—as a health disparity—the 3. After release, residents of states that have
disproportionate incarceration of African not expanded Medicaid (19 states as of
Limitations Americans for drug offenses. Drug abuse January 2016103) will have fewer resources
Our sample included participants from appears to have greater consequences for available to them as federal funding de-
only 1 jurisdiction and may not be racial/ethnic minorities, especially African clines for safety net services.104,105 Nearly

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AJPH RESEARCH

80% of funding for SUD treatment comes Zaoli Zhang, MS, prepared the data and generated 14. Lederman CS, Dakof GA, Larrea MA, Li H. Char-
modified diagnostic algorithms. Jessica Jakubowski, PhD, acteristics of adolescent females in juvenile detention. Int J
from public sources, of which Medicaid and Hongyun Han, PhD, provided assistance preparing Law Psychiatry. 2004;27(4):321–337.
accounts for approximately one fourth.106 data. Celia Fisher, PhD, provided invaluable advice on the 15. Hockenberry S. Juveniles in residential placement,
4. Even in states that expanded Medicaid, project. We thank our participants for their time and 2011. Juvenile offenders and victims: National Report
willingness to participate, as well as the Cook County
specialty outpatient services (where most Juvenile Temporary Detention Center, Cook County
Series Bulletin. Rockville, MD: US Department of Jus-
tice, Office of Juvenile Justice and Delinquency Pre-
SUD treatment takes place) that accept Department of Corrections, and Illinois Department of vention; 2014.
Medicaid are unavailable in 40% of Corrections for their cooperation.
16. Teplin LA, Welty LJ, Abram KM, Dulcan MK,
counties105; inpatient programs that have Washburn JJ. Prevalence and persistence of psychiatric
more than 16 beds are not covered.107 HUMAN PARTICIPANT PROTECTION disorders in youth after detention. Arch Gen Psychiatry.
The Northwestern University institutional review board 2012;69(10):1031–1043.
and the Centers for Disease Control and Prevention in-
Substance abuse is among the most serious 17. Massoglia M, Uggen C. Settling down and aging
stitutional review board approved all study procedures
out: toward an interactionist theory of desistance and
health problems in the United States. Illicit drug consistent with federal regulations regarding research with
the transition to adulthood. AJS. 2010;116(2):
minimal risk.
use and excessive alcohol consumption cost 543–582.
$193 billion108 and $223.5 billion per year,109 18. Wiesner M, Kim HK, Capaldi DM. History of
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