Pattern of Substance Use and Related Factors in Male Prisoners.

BACKGROUND: Prisoner's addiction is one of the major problems in many countries which imposes very high medical costs and social harm to communities. This study investigated the pattern of substance use and related factors in male prisoners in one of the prisons in southeastern Iran.
METHODS: This cross-sectional study was carried out in 2016. The study population was inmates of a prison in southeast Iran. Sampling was carried out randomly according to the list of prisoners. Data were collected using a form and were analyzed with statistics software SPSS.
FINDINGS: More than four-fifths (75.3%) of the subjects consumed at least one substance (alcohol, tobacco and other drugs), 74.4% were smoking, 73.2% used a narcotic substance, and about one-fifth (19.3%) reported drinking alcohol. With a frequency of 62.0%, opium was the most frequently utilized narcotic substance. Poppy juice (31.6%), cannabis (29.8%), crystal (16.9%) and tramadol (16.9%) were the next frequent substances used. A percentage of 41.5% subjects reported using two or more drugs. A percentage of 80.7% subjects reported substance use among their friends, 39.2% by siblings and 37.2% by father. Regression analysis showed predictor variables of substance use were education, substance use by prisoner before being imprisoned, substance use by father, friends and siblings.
CONCLUSION: This study showed a remarkable prevalence of substance use in prisons, which was more than general population. Therefore, it is necessary to consider alternative penalties of imprisonment due to the factors associated with substance use. Screening of people at high risk for substance use should be considered on admission to prison, and primary prevention measures should be focused on them.

Introduction

Prisoners’ substance use, as a challenge for many countries in the world, is a great waste of human and financial capital which imposes several health costs and social harms to communities.1 Estimates in various countries in Europe and Asia, particularly Central Asia have revealed that the proportion of addicts among prisoners is more than the proportion of addicts out of prisons and in the community.2,3

Studying substance use among prisoners is necessary in many aspects. Many problems inside the prisons are directly or indirectly associated with substance use and in addition to having adverse impact on the health of prisoners, it could inflict significant harm and large costs.4,5

Prison is a specific and challenging social setting where the structures of life are very different from outside. Prisoners do not have their own individual free will and spend their sentences in an algebraic system with specific limitations. In addition, the effect of different environment and groups of the society is far more different in prison. In prisons, the prisoner is under a lot of pressure and trauma placed by the prison environment. Uniformity and closed prison environment can result in depression and behavioral disorders in people.6 Using various drugs and substances to relieve anxiety, depression, and other mental problems can be considered as an important factor to the high prevalence of substance use in prisons.7 Limitations and lack of access to many of their desires also result in behavioral deviations in them.5

Substance use in Iranian prisons remains in an alarming rate: according to available data, the average consumption of substances in these prisons is estimated to be between 20% to 80%. Iran is located in proximity to Afghanistan, therefore a considerable percentage of crimes are related to drugs (about 60%).8-10

A large percentage of young inmates would return to the society after serving their sentence. If these people enter society with damage or harm, it would spread social harms, and social costs will rise.5 Some studies have revealed that the pattern of substance use in prisoners changed after entering prison.3-6 In one study, it was estimated that about 60% of prisoners were in prison due to substance-related issues, and, tend to continue SU in prison.11 Certainly, various studies have estimated the prevalence to be between 20% to 80%.6,7,12

substance use in prison, as well the spread of blood-borne diseases such as acquired immune deficiency syndrome (AIDS), would result in the social problems and behavioral disorders as well as imposing a high cost on prisons and the community.13 With all these issues, there is a need to address the prevalence of SU patterns in prisons. Reasons such as proximity to Afghanistan as the leading opium producer in the world and history of substance use in southeast of Iran are challenges in substance use.4 Therefore, the aim of this study was to investigate the pattern of substance use and its related factors among male prisoners in a prison in southeast Iran.

Methods

This cross-sectional study was carried out from January to March 2015. The study population was male inmates of a prison in southeast Iran. Sampling was carried out randomly according to a list of prisoners. Considering the prevalence of 60% and type I error as 0.05, a sample size of 368 was calculated. Given the possibility that some prisoners may not participate in the study, the sample size was considered as 400 people.

The study was done using data collection form with questions designed according to the objectives of the study. The first section of the form included questions on demographic characteristics such as age, education and marital status, and the second section included questions on substance use, type of substance used, smoking (tobacco and hookah) and alcohol consumption, and history of substance use in family (father, mother, sibling) and friends.

By definition, substance use is long-term, pathological use of alcohol or drugs, characterized by daily intoxication, inability to reduce consumption, and impairment in social or occupational function; broadly, alcohol or drug addiction.4 In this study, substance use was defined as using alcohol, tobacco or drugs at least once a month.

When collecting the data, the prisoners were assured that the data collection form did not consist their names and that the information will remain confidential. Verbal consent was obtained from all willing participants. For the prisoners who were literate enough to complete the forms, it was completed by them and was thrown in the forms collection box. In subjects who were illiterate or semi-literate, the interviewer read questions for them and given answers were recorded.

After collecting the forms, the partially filled forms were excluded from the study and other data forms were entered into SPSS software (version 19, SPSS Inc., Chicago, IL, USA). Results were presented using descriptive statistics as mean values, standard deviation (SD), median, percentage, tables and charts. For comparisons, chi-square test, Friedman test, Kruskal-Wallis test and logistic regression were used.

Results

Among the 400 samples under study who received data collection form, 68 cases were excluded due to non-completion or incomplete filling of the form. Data from 332 cases (83%) were analyzed. The mean age of study participants was 32.60 ± 9.41 years and their median age was 30 years old. Minimum age was 18 years and maximum was 60 years. Majority of the cases had primary school degree to diploma, and people with university education had the lowest frequency. In terms of marital status, married and widowed people had the highest and the lowest frequency, respectively (Table 1).

Table 1

Demographic characteristics of the male prisoners

Variables and classes		n (%)
Age groups	< 30 years	160 (50.6)
	≥ 30 years	156 (49.4)
Marital status	Single	108 (34.3)
	Married	148 (47.0)
	Divorced	39 (12.4)
	Widowed	20 (6.3)
Education level	Illiterate	59 (19.0)
	Primary	62 (19.9)
	Secondary	75 (24.1)
	High school and diploma	89 (28.6)
	Academic	26 (8.4)

More than four-fifths (75.3%) of prisoners were taking at least one substance (tobacco, narcotic substances or alcohol) at the time of the study. About four-fifths (74.4%) of subjects were smoking. Of all participants, 69.6% were smoking cigarette while 23.5% were using hookah, and 73.2% were taking at least one NA. About one-fifth (19.3%) of subjects also reported consumption of alcoholic beverages (Figure 1).

Figure 1

Frequency of different types of substance use in studied population

Prevalence of narcotic substance use was 79.6% among smokers, and 62.4% in non-smokers. This difference was statistically significant (P = 0.008). The frequency of alcohol consumption among smokers and non-smokers was 22.3% and 10.6%, respectively and this difference was also statistically significant (P = 0.010). The frequency of alcohol consumption in narcotic substance consumers and non-consumers was 24.7% and 4.5%, respectively and was also statistically significant (P < 0.001).

In terms of the type of narcotic substance, opium was the most prevalent (62.0%), with Shireh (31.6%), tramadol (16.9%), heroin (7.2%) and crack (4.2%), coming afterwards. Temgesic consumption (3%) had the lowest frequency among the prisoners (Figure 2).

Figure 2

Frequency of different types of narcotic substance in studied population

About 24.7% of those surveyed were not using any kind of substance. More than a third (33.8%) were using one type of substance and 41.5% were using, two or more types of substances. Among the prisoners who were using substances, the mean ± SD of the number of substances used was 1.6 ± 2.3 and the median was 2, and also the first and third quartiles were 1 and 3, respectively.

In this study, more than four-fifths (80.7%) of the subjects reported substance use among their friends. Among the family members of prisoners, the highest rate of substance use was among siblings (39.2%) and the lowest substance use was reported by the mother (12.7%) (Figure 3).

Figure 3

Frequency of different types of narcotic substance in relatives of studied population

Illiterate prisoners and those with primary school degree had the highest frequency of consuming at least one substance (88.1% and 80.6% respectively) and this difference was statistically significant (P = 0.010), although more than two-thirds of subjects with other education levels also reported taking at least one substance. Prevalence of substance use was higher among prisoners who reported substance use by their friends (P < 0.001), father (P < 0.001), and siblings (P < 0.001). But the frequency of using one substance was not associated with age, marital status and substance use by mothers.

The prevalence of substance use had a statistically significant association with marital status (P = 0.041) with the highest frequency among widowers as (90.0%) and least frequency in married individuals (66.9%).

About 19.3% of the subjects reported alcohol consumption. The highest rate of alcohol use was among widowers (40.0%), and divorced (28.2%), and the lowest in the married (15.5%) and the single (18.5%) and the difference was statistically significant (P = 0.030). Alcohol consumption was not associated with substance use among family members or friends.

Almost 74.5% of subjects were smoking. Smoking (cigarette and hookah) was not associated with age, marital status, education, substance use by a parent, friend, and sibling (Table 2).

Table 2

Prevalence of narcotic use and using at least one substance (alcohol, tobacco) in terms of age, marital status, education, status of substance use in family, friends, father, mother, sibling among subjects

Variables		Narcotic use		At least one substance use
		n (%)	P	n (%)	P
Age groups	< 30 years	119 (74.4)	0.396	124 (77.5)	0.257
	≥ 30 years	113 (72.4)		115 (73.7)
Substance use by father	Yes	104 (83.9)	< 0.001	105 (84.7)	< 0.001
	No	38 (66.7)		44 (69.6)
Substance use by mother	Yes	35 (83.3)	0.066	36 (85.7)	0.056
	No	202 (71.1)		208 (73.2)
Substance use by siblings	Yes	112 (86.2)	< 0.001	113 (86.9)	< 0.001
	No	127 (64.5)		133 (67.5)
Substance use by friends	Yes	210 (78.4)	< 0.001	214 (79.9)	< 0.001
	No	32 (50.8)		35 (55.6)
Education	Illiterate	50 (84.7)	0.081	2 (88.1)	0.010
	Primary	48 (74.4)		50 (80.6)
	Secondary	49 (65.3)		50 (66.7)
	High school and diploma	60 (67.4)		60 (67.4)
	Academic	19 (73.1)		20 (76.9)
Marital status	Single	86 (79.6)	0.041	89 (82.4)	0.746
	Married	99 (66.9)		102 (68.9)
	Divorced	29 (74.4)		29 (74.4)
	Widowed	18 (90.0)		18 (90.0)

Logistic regression analysis showed that substance use before prison by the prisoners [Exp: 2.69, 95% confidence interval (CI) 1.49-4.86], substance use by father (Exp: 2.02, 95% CI 1.05-3.89), substance use by friends (Exp: 2.62, 95% CI 1.30-5.31), secondary school degree (Exp: 3.84, 95% CI 1.21-12.13) and high school degree (Exp: 3.83, 95% CI 1.10-10.18) (academic education as reference group), were specified as predictors of substance use among the prisoners (Table 3).

Table 3

Regression analysis of predictor variables of substance use in the subjects

Variable	B	B	Exp (B)	95% CI for Exp (B)
Education level	Illiterate	-0.024	0.977	0.26-3.56
	Primary	0.770	2.164	0.63-7.34
	Secondary	1.340	3.836	1.21-12.13
	High school and diploma	1.210	3.836	1.10-10.18
	Academic	Reference	-	-
Substance use by prisoner before being imprisoned		0.990	2.690	1.49-4.86
Substance use by father		0.700	2.020	1.05-3.89
Substance use by siblings		0.667	1.940	1.00-3.80

CI: Confidence interval

Discussion

The prevalence of different types of substance use was reported to be high among the prisoners. This is due to the environmental, cultural, and communicational conditions and the connections between people in prison.14 The results of this study are consistent with most previous studies.14-16 This must be highly reflected by the implementation of harm reduction programs. It is also important to note that the high rate of substance use in prisons could not infer the lack of care or presence of lax conditions in the prisons, as prisoners are mostly from low socio-economic groups and the prevalence of this behavior in prisoners-even before entering the prison-is more pervasive than the general population. Also, in Iran, majority of imprisonments are of substance-related crimes.6,7,12,13,17 Studies in various countries have revealed that substance use among prisoners is higher than the general population.3,5 Recent studies on substance use have shown that in one year period, 70% of substance uses are found in prisoners and less than a third in the general population.5 Many studies have reported the prison as a high-risk environment for onset of substance use. In one study, more than 50% of injecting substance addicts reported that their first injection was in the prison.18 For these reasons, punishments alternative to prison can help reduce the prevalence of substance use in this population.

More than four-fifths of prisoners were taking at least one substance (tobacco, substance uses or alcohol). In a study in the prisons of western Iran, the prevalence of substance use was estimated to be approximately 40% which is less than our study.12 Another study in Iran also estimated that the prevalence of substance use in prisons was about 30%.9 A high prevalence of injecting drug use among prisoners has been reported in previous studies in Iran.19 In the present study, one reason for the high prevalence of substance use may be due to proximity to eastern provinces of Iran which are used as transit route for substances.20

Prevalence of using opium, popper juice, tramadol and cannabis was high among the subjects in this study. High consumption of opium represents easier access of prisoners to this substance, and is also consistent with the pattern of substance use in Iran.20 In European countries, cannabis is the most prevalent substance used in prisons which is consistent with the pattern of substance use in the general population.14,15 The reason for higher consumption of opium could be its effects on prisoners. For instance, the use of crystal in closed environment of prison may not be as appealing or desirable as opium for the individual. Substances like opium are used more than stimulants such as amphetamines due to their sedative effects and their role in coping with fears and anxiety.10,21 In other studies, consumption of narcotics has been reported to be more than stimulants among prisoners.6,7,12,13

In this study, the highest and the lowest prevalence of substance use were among the widowers and the married prisoners, respectively, which is consistent with similar studies.12,22,23 Other studies have also reported the lowest prevalence of substance use among married people.22,23 It implies that the main reason for high prevalence in people who have lost their spouse is due to immersed psychological pressure and stress which is a major factor in the tendency to substance use.6

In this study, about one-fifths (19.3%) of the subjects reported alcohol consumption. This rate is about 10% in the general population.24 This difference is considerable and with respect to the prohibition of alcohol in the country and very difficult access to alcohol in prisons, this can occur during their break.24 The highest frequency of alcohol consumption was in widowers (40.0%) and least frequencies were among the married and single prisoners. In other studies, alcohol consumption was reported to be lower in married people than other groups.23,25 About four-fifths of the subjects were smokers and most were smoking cigarette. In similar studies, smoking and tobacco use was high and in the range of 30% to 80%.6,7,12,19,24

The illiterate prisoners had the highest percentage of substance use, followed by people with primary school degree. Nevertheless, in similar studies, the prevalence of substance use was often higher in people with secondary education though the difference between other groups was low and not significant.23 However, in this study, the difference of substance use between the illiterate and secondary education was significant. Another important point is that, the rate of substance use was also high among prisoners with academic education and is about 73%. Perhaps the prison-induced stress is the cause of substance use in prisoner with a university education. Similar studies in this field provided different results and usually underestimated the prevalence of substance use in subjects with academic education.25

There was a significant relationship between substance use in the subjects with substance use by their fathers and friends. Many studies have acknowledged the effect of substance use in family and friends on substance use in individuals, though different percentages are obtained.7,26-28 In a study in Iran, the influence of substance using friends on the tendency to consume substance in individuals was estimated to be about 50% and next factor was the influence of substance use by family.7 In two other studies, the influence of substance use by friends had the highest score among the factors of tendency to substance use with the influence of family and close relatives coming afterwards.26,27 Various studies have also indicated the effect of substance use by peers and relatives as a contributing factor in the risk of substance use in individuals.26,28 substance use before going to prison was an important predictor of substance use in prison in this study. The results of other studies have shown the relationship between substance use before and after prison.7,27

Conclusion

In general, the results of this study showed that the prevalence of substance use was remarkable in prisons and was higher than general population for different reasons. Hence, it is necessary to take alternative sentences to prison into serious consideration. Screening of people at higher risk for substance use should be considered on admission to prison, and primary prevention measures should be focused on them.