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The International Journal of the Addictions. 12(8). 1155-1 178. 1977
Drug Abuse in South Carolina: Comparison with Three Studies lsis Istiphan, Ph.D. South Carolina Commission on Alcohol and Drug Abuse Columbia. South Carolina 29240
Abstract
This report discusses results of a state study on drug abuse in South Carolina and compares them with those of a similar state study conducted the previous year, as well as with three national studies. Since the latter did not deal with all the specific aspects of the state study, only the relevant portions are compared. The first of the national studies is on assessment of the diffusion of heroin abuse to medium-sized American cities. The second is on teenage drug abusers admitted to treatment. The third is on students and drugs in colleges and high schools. The purpose of this report is twofold: (1) to give highlights of a state study on drug abuse in South Carolina and (2) to compare some of the results with results of three national reports.
Copyright @ 1978 by Marcel Dekker, Inc. All Rights Reserved. Neither this work nor any part may be reproduced or transmitted in any lorm or by any means, electronic or mechanical, including photocopying, microfilming, and recording, or by any inl’ormation storage and retrieval system, without permission in writing from the publisher.
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STATE STUDY The study was originally undertaken for the State Plan on Drug Abuse in preparation of grant requests from the National Institute on Drug Abuse. The methodology followed guidelines given by the Special Action Office on Drug Abuse Prevention (SAODAP). Some modifications were added to adapt the collection of data to state needs. The wealth of information gathered made it possible not only to update the State plan but to use the data for various other purposes. Methodology
Survey forms were used as an instrument for data gathering and included questions on demographic characteristics of clients as well as the drugs of abuse. The forms contained certain other information pertaining to the specific agencies involved. The participants were all service delivery agencies, public and private, dealing with drug abuse. Agencies included Departments of Social Services, Mental Health, Corrections, Education, Health and Environmental Control, and the Law Enforcement Agencies, Hospital Emergency Rooms, Private Treatment Programs, Coroners, Physicians, and all County Commissions on Alcohol and Drug Abuse. Since there was a large number of physicians, a 25% sample was selected through the random sample method and survey forms were mailed to them. The best returns came from the Alcohol and Drug Addictions Center, the Vocational Rehabilitation Center, Department of Corrections, Department of Social Services, and the Hospital Emergency Rooms (92 to 100%). These were followed by the Community Mental Health Centers, Probation and Parole Boards, and the Military, which range between 86 and 677; returns. The 66 treatment, education, and prevention programs returned 47% of the forms while the coroners returned 43% and the public health nurses 39%. Returns from the junior and senior high schools were quite low, 24 and 29%. Only 13% of physicians responded in spite of two attempts to contact them. (See Table 1.) To obtain an unduplicated count, the total number of dysfunctional drug abusers was divided by a factor of 0.50. The system was obtained from two previous separate studies conducted in the state. The method in both studies was to bring representatives from each of the treatment agencies in a county to attend a closed meeting. One agency representative
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DRUG ABUSE IN SOUTH CAROLINA
Table 1 Report of Agencies' Response to Survey
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Agencies Emergency rooms Junior school counselors Senior school counselors Department of social services Drug-related deaths Public health nurses Probation and parole board Client data Alcohol and drug addiction Vocational rehabilitation
% received
No. of cases
Period covered
54 18 88
92
3,398
3 months r l year I year
46 46 46
43 20 18
93 43 39
1,047 325 199
1 year 1 year 1 year
46 66
34 27
74 47
1,685 2,615
1 month
1 14
1BMcards Computer printouts 6
100 100
341 260
1 year 1 year
67 100
1,222 521 1,831
1 year
13 86
880 2,237
1 year 1 year
Total sent
Total received
59 79 460
Military Department of corrections Drug arrests
9
Physicians Community mental health
880 14
1
1
Computer printouts I12 12
24 1 19 j
578
1 year
1 year 1 year
would read the list of his clients while the others checked their lists to determine if they also had worked with the same client. As agency representatives continued that process for all clients in the counties, the duplication factor was determined. This same factor, 0.50, is the one applied in this study. In summary, the method used to obtain data provided stable estimates mainly because of the multiplicity of data sources and the procedures followed to obtain an unduplicated count of cases. To maintain confidentiality of client records and follow the federal regulations, researchers are usually forced to devise means for cutting down on duplications as much as possible. The 0.50 factor used in this study is an example of such efforts. The governor's 10 Planning Regions were selected as the standard method of dealing with the data. By using these regions, it was easier to compare the data with those coming from other sources in the state. To analyze the data, information from the survey was computerized. Nineteen drugs were classified into 10 major drug categories and data
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were analyzed according t o age, sex, race, region, and county of residence. Cross ta‘bulations were performed to find various demographic attributes, differences, or similarities in the data. To develop the profile of a particular drug abuser, the data were broken down by drug of abuse, sex, race, and age. From this breakdown a picture of the typical drug abuser was drawn for the 10 major drug categories. The term “dysfunctional drug abuser” was used in the study to mean an individual who by virtue of his use of substances has had an encounter with the social institutions. The term “encounter’’ means some contact either by apprehension or arrest with a judiciary system, referral to a mental health or some related treatment or community program, or admission to an emergency room or contact with a physician regarding substance of abuse. “Polydrug” is defined as the use of two or more drugs either sequentially or simultaneously by one person. Analysis of Data
This section will discuss dysfunctional drug abuse according to age, sex, race, and region. Six drugs ranked highest among the age group 18 to 25. These were: heroin (72’i.;,), marijuana 59”/;;,depressants (34%), stimulants (5473, narcotics (6Q,), and hallucinogens (63%). Polydrugs also ranked highest among those under 18 with 47%. Alcohol ranked highest among those 36 to 49 years of age. Those under 18 ranked second in marijuana incidents, depressants, stimulants, hallucinogens, and polydrugs. Other age groups that ranked second were those 26 to 35 years of age in narcotics and those 18 to 25 in inhalants and those 26 to 35 in heroin and in alcohol. (See Table 2 and Figs. 1-5.) Males ranked highest in all the drugs except depressants. They ranged between 71 and 79% except for the polydrugs where the differences were 60 to 40%. Among the depressants the females ranked higher than the males with 56 to 44%, respectively. Incidence of dysfunctional drug abuse ranked highest among Whites in all drugs except heroin, with percentages ranging in the 70s and 80s. The heroin incidents among Blacks were 52% compared to 48% among Whites. Differences among the narcotic incidents were small between the two groups, with 54% among Whites and 46% among Blacks. Alcohol abuse was higher among Whites than Blacks with 67%. A profile of the dysfunctional drug abuser was developed through a special computer program which was devised to combine all the demographic characteristics under each of the reported drug types in such a
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DRUG ABUSE IN SOUTH CAROLINA
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manner that every drug would represent a specific age group, sex, and race. Profiles were drawn to describe the typical drug abuser. Results showed that those who ranked first were White males between the ages of 18 and 25 in each of six drugs: marijuana, depressants, stimulants, narcotics, hallucinogens, and polydrugs. Those ranking first in inhalants were White males under the age of 18 and those ranking first in alcohol were White males between the ages of 36 and 49. The only Blacks who ranked first in this analysis were males between the ages of 18 and 25 in the heroin incidents. The only females who ranked second were Whites between the ages of 18 and 25 in incidents of depressants. White females under the age of 18 ranked third in four types of drugs: stimulants, hallucinogens, and polydrugs. White females between the ages of 26 and 35 ranked third in incidents of depressants while White males in the same age group ranked third in alcohol incidents. The only Blacks ranking third in this group were males between the ages of 18 and 25 in marijuana incidents. (See Table 3 . ) In ranking the drugs, marijuana incidents were the highest in the state followed by depressants, polydrugs, stimulants, heroin, hallucinogens, and inhalants. Compared to the previous year’s study, the ranking was the same except for depressants and marijuana in which the order was reversed. Returns from the physician’s survey last year were greater than returns of this year’s study. The physicians reported the highest incidence of depressants in the two studies. It is to be noted that heroin continued to rank fifth among the drugs in South Carolina, contrary to the nationwide figures. In examining the governor’s 10 Planning Regions, it was clear the Appalachian Region ranked highest in drug incidents in the state followed by the Central Midlands Region and the Berkeley-Charleston-Dorchester Region. The populations of these three regions ran highest in the state. The Appalachian Region had 25.331,, of the total state population, while the Central Midlands had 14.3:/; and Berkeley-Charleston-Dorchester had 12.987;. The college and high school populations also ranked highest in the state with the three regions ranking in the same order as given above. The concentration of the types of drugs vary from one region to another. In the Appalachian Region, the highest incidents were in the depressants, followed by polydrugs, hallucinogens, inhalants, and alcohol. In the Central Midlands, the incidents were those of marijuana, stimulants, and narcotics. In the Berkeley-Charleston-Dorchester Region, heroin ranked the highest in the state. (See Table 2.) The locations of these three regions are significant in relation to the
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Table 2 Incidents of Dysfunctional Drug Abuse in the State of South Carolina According
Drug types Alcohol
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Demographiccharacteristics
No.
%
Heroin
No.
%
Marijuana NO.
%
Age 269 8.45 40 7.85 651 29.54 Under 18 18-25 460 14.44 364 72.19 1306 59.26 26-35 750 23.55 83 16.48 210 9.51 17 0.75 36-49 1027 32.24 12 2.38 Over 49 21 0.94 6 1.09 679 21.32 Sex Male 2307 72.14 386 76.51 1740 79.16 Female 891 27.86 119 23.49 458 20.84 Race White 2095 67.17 243 48.17 1511 76.62 Black 1014 32.52 261 51.64 456 23.10 6 0.28 1 0.20 10 0.30 Indian Other Regions 644 20.23 66 16.62 341 16.13 I-Appalachian 58 2.72 202 6.33 6 1.51 11-Upper Savannah 76 3.58 283 8.77 31 7.68 111-Catawba 261 8.20 88 22.17 537 25.43 IV-Central Midlands 76 3.60 296 9.30 8 2.01 V-Lower Savannah 364 11.43 42 10.58 159 7.51 VI-San tee-Wateree 15 3.65 225 10.63 542 17.01 VII-Pee Dee 34 1.61 VIII-Waccamaw 130 4.10 17 4.16 IX-Berkeley, Charleston, 265 8.32 117 29.47 339 16.05 Dorchester 198 6.22 9 2.14 269 12.74 X-Low Country -------3194 100.0 505 100.0 2114 100.0 Total
Depressants No.
%
353 510 289 223 128
23.50 33.92 19.21 14.85 8.52
663 44.06 841 55.94 1258 85.17 217 14.69 2 0.14
341 22.73 93 6.16 141 9.36 255 16.96 56 3.70 136 9.06 185 10.96 85 5.63 168 11.16 64 4.27 1504 100.0
DRUG ABUSE IN SOUTH CAROLINA
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to Drug Types by Age, Sex, Race, and Region July 1973-June 1974
Drug types Stimulants
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No.
%
Narcotics
No.
%
Hallucinogens
No.
%
Inhalants
No.
%
Other No.
%
Polydrug
No.
%
160 24.90 346 53.71 91 14.09 24 3.66 23 3.58
54 8.51 425 67.57 111 17.65 21 3.34 18 2.86
138 304 36 3 3
28.53 62.97 7.37 0.62 0.52
56 57.14 237 31.04 33 33.67 263 34.45 6 6.12 156 20.43 1 0.51 74 9.69 3 2.55 34 4.39
378 590 193 119 75
27.85 43.60 14.28 8.76 5.51
426 74.80 144 25.20
450 71.77 177 28.23
352 129
73.15 28.85
74 74.62 25 25.32
308 40.25 457 59.75
808 549
59.55 40.45
546 85.64 337 53.92 89 13.97 287 45.92 1 0.16 3 0.39
408 67 5
85.16 13.90 0.94
80 80.71 536 72.11 19 19.29 206 27.62
1082 305
77.15 21.85 0.36
122 19.10 11 1.65 47 7.39 167 26.18 16 2.52 56 8.73 68 10.69 16 2.52
111 14 43 78 22 40 28 9
23.74 2.99 9.09 16.58 4.71 8.55 5.88 1.93
32 5 11 14 3 10 12 0
275 33 143 267 38 115 178 42
20.42 2.45 10.62 19.79 2.82 8.50 13.18 3.12
99 16.81 17 2.88 38 6.45 180 30.56 16 2.72 46 7.81 18 3.06 23 3.90
31.44 5.15 10.82 13.92 2.58 9.79 12.37 0
189 24.6 68 8.88 63 8.17 159 20.72 64 8.30 19 2.42 41 5.36 48 6.28
92 14.38 132 22.41 100 21.28 9 9.28 61 7.91 203 15.04 20 3.40 25 5.35 54.64 56 7.32 55 4.05 -~ 21 3.30 616 100.0 589 100.0 470 100.0 101 100.0 768 100.0 1349 100.0
Fig. 1.
Dysfunctional drug abuse within specific age groups according to drug types
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4
!3
1
8
: *
.. .. .. ..
..
m 0 h 0
.o 0 0 0 \f 0 m 0
N
0
ALCOHOL
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HEROIN
MARIJUANP
W
2
DEPRESSANT!
3
g. J
% a
2
gr,
STIMULANT!
6 0,
g
NARCOTIC
09
W
a
5
HALLUCINOGEN
m
INHALENT
OTHE
PO LYD R l c
0
6
I2
f 0
I:
0,
-4
0
0
m 0
:I
I
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ALCOHOL
HEROIN
MARIJUAM
DEPREWS
STIMULANTS
NARCMICS
HALLUCINOGENS
INHALENS
OMER
POLYORUG
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DRUG ABUSE IN SOUTH CAROLINA
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Table 3 Profile of the Dysfunctional Drug Abuser"
Rank Drug type
I
Marijuana Depressants Stimulants Narcotics Heroin Hallucinogens Inhalants Polydrug Alcohol
WM 18-25 WM 18-25 WM 18-25 WM 18-25 BM 18-25 WM 18-25 WM 18 WM 18-25 WM 36-49
I1
I11
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~
W
=
White, B
=
Black, M
=
male, F
WM 18 W F 18-25 WM 18 BM 18-25 WM 18-25 WM 18 WM 18-25 W.M 18 WM over 49 =
BM 18-25 WF 26-35 WF 18 WF 18-25 WF 18-25 WF 18 WF 18 WF 18 WM 26-35
female.
interstate highway systems. The Berkeley-Charleston-Dorchester Region is located in an area with an interstate highway which connects it with the Central Midlands and Appalachian Regions and with another interstate which runs from Florida to North Carolina. There is a state route that leads to Myrtle Beach where there is a military installation. That area has a network of routes leading to Sumter (another military installation), to North Carolina, and to the Central Midlands Region. There are three military installations in Charleston (an Air Force Base, a Naval Base, and a Naval Hospital) which include a large number of military personnel and their families. There are four educational institutions, 27 junior and senior high schools, and a technical education school in the area which increase the concentration of the youth population.. The ready accessability of the region through land and sea makes it an easy target for the drug traffic. This fact and the very high percentage of the youth age groups have great bearings on the incidents of dysfunctional drug abuse in the area. Heroin incidents in this area are the highest in the state and give indications that there can be a relationship between the geographical location of this region and the high incidents. This point will be taken up later while discussing one of the three studies mentioned above. The Central Midlands Region is located in the center of the state and includes Columbia, the state capitol. A whole network of interstate and state routes passes through Columbia. One route connects it with North Carolina, another route connects it with Atlanta. There is an interstate
ISTIPHAN
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1168
route which comes from Florida and connects with another interstate route passing through Columbia. The third is the Appalachian Region with Greenville and Spartanburg counties having interstate routes connecting them with Georgia and North Carolina as well as with Columbia. The geographical location plus the high concentration of college and high school populations and a developed interstate system make the area vulnerable to drug abuse. South Carolina is located between New York and Florida and is midpoint between South Atlantic and South American nations and the eastern United States. It has seaports and an accessible coastline as well as airports. There is tourist trade and cultural exchange. All these along with the developed interstate system attract drug traffic and encourage its extension to the South Carolina communities.
COMPARISON OF STATE STUDY WITH THREE NATIONAL STUDIES Study # I
The first study to be compared with some of the findings of the state study (Istiphan et al., 1975) is the Assessment of the Diffusion of Heroin Abuse to Medium Sized American Cities. A survey was conducted by the Special Action Office for Drug Abuse Prevention during June 1974, concerning the incidence and prevalence of heroin abuse in 10 American cities (Green et al., 1974). The study was undertaken for two basic reasons: (1) Evaluation of the “ripple theory,” and (2) evaluation of heroin incidence and prevalence methodology. The “ripple theory” states that as time passes, the likelihood of finding epidemic heroin use in large cities (population greater than 300,000)decreases, while the likelihood of finding epidemic heroin use in cities of smaller size increases. The first major goal of the project was to select a sample of 10 medium-sized cities from different regions of the United States and try to determine the status of heroin abuse in each. If the “ripple theory” were correct, one would expect to find current epidemic heroin use at least in some of the cities studied. Several researchers attempted to assess patterns and trends of heroin use at the local level and proposed a number of indicators of the nature and extent of heroin use. These indicators attracted a great deal of interest and criticism, but no attempt was made to assess their applicability in different communities. The second major study goal was to gain ex-
DRUG ABUSE IN SOUTH CAROLINA
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perience in applying the indicators in a wide variety of communities and attempt to assess their utility as measures of heroin use incidence and prevalence. The indicators viewed included the following: a. b. c. d. e. f. g.
Data obtained from heroin addicts entering treatment Hepatitis Data Heroin Overdose-Death Heroin Overdose-Emergencies Law Enforcement Data Data from the University Community Data from the Military Community
The study collected only such data as currently existed in the various communities and no special studies were initiated as part of the project. The following discussion addresses the issue of how useful each of the data sources employed was found to be. A comparison will be made between these findings and those of the state study. a. Treatment Data: The researchers found the relative incidence of heroin use as measured by year of first heroin use reported by treatment of heroin addicts to be the most reliable indicator used. In spite of the numerous objections that were raised regarding its use, the index of heroin incidence, when corrected for lag, appeared to accurately describe the local heroin situation in almost every city visited. In no instance was treatment-derived incidence basically at variance with other data obtained. Combining treatment-based incidence data with the more graphic characteristics of the users has proved to be a remarkably sensitive tool. The researchers found that the application of that technique should substantially reduce the objections initially raised to use of treatment-based information as an indicator of heroin incidence. In the state study, data obtained from the treatment programs showed the highest incidence of heroin. Most of the programs follow a data collection system called CODAP (Client Oriented Data Acquisition Process) which requires information on first use of the drug. In this instance the reliability of the technique will be substantiated or refuted
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when time reveals whether the indidence trends projected in each situation actually occur as predicted.
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b.
Hepatitis Data: The state study did not gather data on hepatitis incidence. c. Heroin Overdose-Death: The researchers found their sources of information to be disappointing. Virtually all of the cities visited lacked the framework necessary for drugrelated death data to be of value. They indicated the need for a well-trained medical person involved in the investigation of death of undetermined etiology, an interest in drugs as a cause of death, and the willingness to be frank about deaths of this etiology; there was need for some set of diagnostic criteria by which cases are classified as drug related or not; there was need for reliable toxicology with a keen toxicological screening of all cases in which the cause of death is not obvious, particularly in individuals less than 14 years of age; there was need for a good record-keeping system that gives interested parties access to the data on drug-related death.
In the state study similar difficulties were experienced. Moreover, only 430; of the coroners answered the questionnaires. Among all the drugrelated deaths reported, 2% were recorded as due to heroin. Compared to all the heroin cases reported by agencies in the state, 9”/, were reported by the coroners. d.
Heroin Overdose-Emergencies: With two exceptions, the researchers found that none of the hospitals visited had record-keeping systems that permitted access to records of patients seen in the emergency rooms from heroin overdose (or any drug-related problem, for that matter). Besides the record-keeping issue, it was found that many hospitals were not interested in rendering care to individuals who were drug abusers, and still others actively discouraged such people from seeking care there. It was also felt that those who seek care in a hospital emergency room for a heroinrelated problem run a high risk of being reported to the police and therefore might have been reluctant to seek such help.
In the state study the hospital emergency rooms’ returns were 92%
DRUG ABUSE IN SOUTH CAROLINA
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compared to returns from other programs. These included all drug incidents. Compared to the reports on heroin cases from other agencies, the emergency rooms reported heroin in 4y4, of their cases. It is possible, as was suspected by the researchers, that people fear to report to the hospital when they have a heroin problem. e. Law Enforcement Data: The relationship between property crime and heroin use incidents, as assessed by a crude comparison of two indices, appears to be erratic at best. I t was found difficult to use the property crime rate as a primary predictor of heroin trends, and it was suggested that the indices would be tested in a community with homogeneous heroin-using populations in order to clarify the illusive relationship between drug use and crime. In the case of the state study, reports do not separate heroin from other cases of narcotic drug abuse. There was a +10.6”;, change in burglary as compared to 19.3:/, in narcotic drug abuse.
+
f.
University Community: With few exceptions, this index was of no value to the researchers as a source of information regarding heroin abuse. It was felt that students did not go to the University Health Services for assistance in dealing with heroin-related illness, or that University Health Officials were unwilling to reveal potentially sensitive information to federal investigators, or there really was not much of a heroin problem on college campuses. They suggested that probably in the future such indices should be deleted.
In the state study, most of the health centers to which survey forms were sent did not respond. No data were gathered directly from the universities themselves. Survey forms, however, were sent to school counselors in the junior and senior high schools. The returns were very low: 20%. Only 27; of the cases were reported as heroin cases. g.
Military Community: The purpose of visiting military facilities was to evaluate any possible relationship between military personnel and members of the adjacent civilian community. There was no evidence to suggest that the civilian heroin situation was the source of drug-abuse problems for military personnel stationed nearby or vice versa
ISTIPHAN
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1172
In the state study, six out of the nine military bases responded to our questionnaire. Eight percent reported heroin cases compared to all such cases reported by other agencies. Some of the bases had a civilian community living near their headquarters. These usually are families of the military men or some of the retired military people themselves. One military base reported meeting the needs of civilians who have association with the base. No effort was made in this study to see whether there was a relationship between the military personnel and civilian population or vice versa. The “ripple theory”: Fact or fantasy? The question is posed by the researchers whether the theory was refuted or validated. The answer is both yes and no depending on the point in time at which the theory was applied. To the extent to which the “ripple theory” puts forth a model of the spread of heroin use, a model based on diffusion of heroin-using behavior from large cities toward small cities as time passes, it would appear that the model has been validated. In five of the cities studied there was a 1-year lag between the nearest major urban center and the study city with regard to peak year of heroin use. The two exceptions were Racine, which peaked in the same year as its nearest major city, Chicago; and Greensboro, in North Carolina, which is located approximately halfway between New York City and Miami, a major distribution corridor for heroin. One could hypothesize that it was a convenient stopover site for those carrying heroin up and down the East Coast. In both these cities, Racine and Greensboro, the peak was in the same year as its nearest major city. In the state study the heroin incidents were very small in the past 2 years. Charleston, however, had the highest incidence of heroin in the state and it is located almost halfway between Miami, Florida, and Greensboro, North Carolina. To the extent that the researchers anticipated finding raging current heroin epidemics in the country’s medium-sized cities, the “ripple theory” was not supported. The researchers concluded that the data would appear to support the validity of the geo-temporal diffusion model of heroin use spread. This diffusion process occurs more rapidly than initially suspected but it does occur both from major urban centers to medium-sized cities, and probably from medium-sized cities to their smaller neighbors. Study # 2
The CODAP Reporting System: The Case of Teen-Age Abusers Admit-
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DRUG ABUSE I N SOUTH CAROLINA
I I73
ted to Treatment (Spillane and Ryser, 1974). The paper highlights a quantitative analysis of the results of the first 6 months of CODAP implementation in the United States. The specific purpose of the paper addressed some of the results derived from an analysis of the client admissions data collected from April through September 1973. In addition, the report included general patterns, areas of concentration, and the broad direction in which future analysis should be pursued. Another feature which will not be considered in this paper deals with a discussion of an important lag variable concept which was devised from the CODAP data. Variables of age, sex, race, and drug types discussed in the national study will be compared with those in the state study. Supplementary information will be added from those agencies that complete CODAP forms.,The national CODAP report showed that there were 75?
The International Journal of the Addictions. 12(8). 1155-1 178. 1977
Drug Abuse in South Carolina: Comparison with Three Studies lsis Istiphan, Ph.D. South Carolina Commission on Alcohol and Drug Abuse Columbia. South Carolina 29240
Abstract
This report discusses results of a state study on drug abuse in South Carolina and compares them with those of a similar state study conducted the previous year, as well as with three national studies. Since the latter did not deal with all the specific aspects of the state study, only the relevant portions are compared. The first of the national studies is on assessment of the diffusion of heroin abuse to medium-sized American cities. The second is on teenage drug abusers admitted to treatment. The third is on students and drugs in colleges and high schools. The purpose of this report is twofold: (1) to give highlights of a state study on drug abuse in South Carolina and (2) to compare some of the results with results of three national reports.
Copyright @ 1978 by Marcel Dekker, Inc. All Rights Reserved. Neither this work nor any part may be reproduced or transmitted in any lorm or by any means, electronic or mechanical, including photocopying, microfilming, and recording, or by any inl’ormation storage and retrieval system, without permission in writing from the publisher.
ISTIPHAN
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STATE STUDY The study was originally undertaken for the State Plan on Drug Abuse in preparation of grant requests from the National Institute on Drug Abuse. The methodology followed guidelines given by the Special Action Office on Drug Abuse Prevention (SAODAP). Some modifications were added to adapt the collection of data to state needs. The wealth of information gathered made it possible not only to update the State plan but to use the data for various other purposes. Methodology
Survey forms were used as an instrument for data gathering and included questions on demographic characteristics of clients as well as the drugs of abuse. The forms contained certain other information pertaining to the specific agencies involved. The participants were all service delivery agencies, public and private, dealing with drug abuse. Agencies included Departments of Social Services, Mental Health, Corrections, Education, Health and Environmental Control, and the Law Enforcement Agencies, Hospital Emergency Rooms, Private Treatment Programs, Coroners, Physicians, and all County Commissions on Alcohol and Drug Abuse. Since there was a large number of physicians, a 25% sample was selected through the random sample method and survey forms were mailed to them. The best returns came from the Alcohol and Drug Addictions Center, the Vocational Rehabilitation Center, Department of Corrections, Department of Social Services, and the Hospital Emergency Rooms (92 to 100%). These were followed by the Community Mental Health Centers, Probation and Parole Boards, and the Military, which range between 86 and 677; returns. The 66 treatment, education, and prevention programs returned 47% of the forms while the coroners returned 43% and the public health nurses 39%. Returns from the junior and senior high schools were quite low, 24 and 29%. Only 13% of physicians responded in spite of two attempts to contact them. (See Table 1.) To obtain an unduplicated count, the total number of dysfunctional drug abusers was divided by a factor of 0.50. The system was obtained from two previous separate studies conducted in the state. The method in both studies was to bring representatives from each of the treatment agencies in a county to attend a closed meeting. One agency representative
1157
DRUG ABUSE IN SOUTH CAROLINA
Table 1 Report of Agencies' Response to Survey
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Agencies Emergency rooms Junior school counselors Senior school counselors Department of social services Drug-related deaths Public health nurses Probation and parole board Client data Alcohol and drug addiction Vocational rehabilitation
% received
No. of cases
Period covered
54 18 88
92
3,398
3 months r l year I year
46 46 46
43 20 18
93 43 39
1,047 325 199
1 year 1 year 1 year
46 66
34 27
74 47
1,685 2,615
1 month
1 14
1BMcards Computer printouts 6
100 100
341 260
1 year 1 year
67 100
1,222 521 1,831
1 year
13 86
880 2,237
1 year 1 year
Total sent
Total received
59 79 460
Military Department of corrections Drug arrests
9
Physicians Community mental health
880 14
1
1
Computer printouts I12 12
24 1 19 j
578
1 year
1 year 1 year
would read the list of his clients while the others checked their lists to determine if they also had worked with the same client. As agency representatives continued that process for all clients in the counties, the duplication factor was determined. This same factor, 0.50, is the one applied in this study. In summary, the method used to obtain data provided stable estimates mainly because of the multiplicity of data sources and the procedures followed to obtain an unduplicated count of cases. To maintain confidentiality of client records and follow the federal regulations, researchers are usually forced to devise means for cutting down on duplications as much as possible. The 0.50 factor used in this study is an example of such efforts. The governor's 10 Planning Regions were selected as the standard method of dealing with the data. By using these regions, it was easier to compare the data with those coming from other sources in the state. To analyze the data, information from the survey was computerized. Nineteen drugs were classified into 10 major drug categories and data
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1158
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were analyzed according t o age, sex, race, region, and county of residence. Cross ta‘bulations were performed to find various demographic attributes, differences, or similarities in the data. To develop the profile of a particular drug abuser, the data were broken down by drug of abuse, sex, race, and age. From this breakdown a picture of the typical drug abuser was drawn for the 10 major drug categories. The term “dysfunctional drug abuser” was used in the study to mean an individual who by virtue of his use of substances has had an encounter with the social institutions. The term “encounter’’ means some contact either by apprehension or arrest with a judiciary system, referral to a mental health or some related treatment or community program, or admission to an emergency room or contact with a physician regarding substance of abuse. “Polydrug” is defined as the use of two or more drugs either sequentially or simultaneously by one person. Analysis of Data
This section will discuss dysfunctional drug abuse according to age, sex, race, and region. Six drugs ranked highest among the age group 18 to 25. These were: heroin (72’i.;,), marijuana 59”/;;,depressants (34%), stimulants (5473, narcotics (6Q,), and hallucinogens (63%). Polydrugs also ranked highest among those under 18 with 47%. Alcohol ranked highest among those 36 to 49 years of age. Those under 18 ranked second in marijuana incidents, depressants, stimulants, hallucinogens, and polydrugs. Other age groups that ranked second were those 26 to 35 years of age in narcotics and those 18 to 25 in inhalants and those 26 to 35 in heroin and in alcohol. (See Table 2 and Figs. 1-5.) Males ranked highest in all the drugs except depressants. They ranged between 71 and 79% except for the polydrugs where the differences were 60 to 40%. Among the depressants the females ranked higher than the males with 56 to 44%, respectively. Incidence of dysfunctional drug abuse ranked highest among Whites in all drugs except heroin, with percentages ranging in the 70s and 80s. The heroin incidents among Blacks were 52% compared to 48% among Whites. Differences among the narcotic incidents were small between the two groups, with 54% among Whites and 46% among Blacks. Alcohol abuse was higher among Whites than Blacks with 67%. A profile of the dysfunctional drug abuser was developed through a special computer program which was devised to combine all the demographic characteristics under each of the reported drug types in such a
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DRUG ABUSE IN SOUTH CAROLINA
1159
manner that every drug would represent a specific age group, sex, and race. Profiles were drawn to describe the typical drug abuser. Results showed that those who ranked first were White males between the ages of 18 and 25 in each of six drugs: marijuana, depressants, stimulants, narcotics, hallucinogens, and polydrugs. Those ranking first in inhalants were White males under the age of 18 and those ranking first in alcohol were White males between the ages of 36 and 49. The only Blacks who ranked first in this analysis were males between the ages of 18 and 25 in the heroin incidents. The only females who ranked second were Whites between the ages of 18 and 25 in incidents of depressants. White females under the age of 18 ranked third in four types of drugs: stimulants, hallucinogens, and polydrugs. White females between the ages of 26 and 35 ranked third in incidents of depressants while White males in the same age group ranked third in alcohol incidents. The only Blacks ranking third in this group were males between the ages of 18 and 25 in marijuana incidents. (See Table 3 . ) In ranking the drugs, marijuana incidents were the highest in the state followed by depressants, polydrugs, stimulants, heroin, hallucinogens, and inhalants. Compared to the previous year’s study, the ranking was the same except for depressants and marijuana in which the order was reversed. Returns from the physician’s survey last year were greater than returns of this year’s study. The physicians reported the highest incidence of depressants in the two studies. It is to be noted that heroin continued to rank fifth among the drugs in South Carolina, contrary to the nationwide figures. In examining the governor’s 10 Planning Regions, it was clear the Appalachian Region ranked highest in drug incidents in the state followed by the Central Midlands Region and the Berkeley-Charleston-Dorchester Region. The populations of these three regions ran highest in the state. The Appalachian Region had 25.331,, of the total state population, while the Central Midlands had 14.3:/; and Berkeley-Charleston-Dorchester had 12.987;. The college and high school populations also ranked highest in the state with the three regions ranking in the same order as given above. The concentration of the types of drugs vary from one region to another. In the Appalachian Region, the highest incidents were in the depressants, followed by polydrugs, hallucinogens, inhalants, and alcohol. In the Central Midlands, the incidents were those of marijuana, stimulants, and narcotics. In the Berkeley-Charleston-Dorchester Region, heroin ranked the highest in the state. (See Table 2.) The locations of these three regions are significant in relation to the
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Table 2 Incidents of Dysfunctional Drug Abuse in the State of South Carolina According
Drug types Alcohol
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Demographiccharacteristics
No.
%
Heroin
No.
%
Marijuana NO.
%
Age 269 8.45 40 7.85 651 29.54 Under 18 18-25 460 14.44 364 72.19 1306 59.26 26-35 750 23.55 83 16.48 210 9.51 17 0.75 36-49 1027 32.24 12 2.38 Over 49 21 0.94 6 1.09 679 21.32 Sex Male 2307 72.14 386 76.51 1740 79.16 Female 891 27.86 119 23.49 458 20.84 Race White 2095 67.17 243 48.17 1511 76.62 Black 1014 32.52 261 51.64 456 23.10 6 0.28 1 0.20 10 0.30 Indian Other Regions 644 20.23 66 16.62 341 16.13 I-Appalachian 58 2.72 202 6.33 6 1.51 11-Upper Savannah 76 3.58 283 8.77 31 7.68 111-Catawba 261 8.20 88 22.17 537 25.43 IV-Central Midlands 76 3.60 296 9.30 8 2.01 V-Lower Savannah 364 11.43 42 10.58 159 7.51 VI-San tee-Wateree 15 3.65 225 10.63 542 17.01 VII-Pee Dee 34 1.61 VIII-Waccamaw 130 4.10 17 4.16 IX-Berkeley, Charleston, 265 8.32 117 29.47 339 16.05 Dorchester 198 6.22 9 2.14 269 12.74 X-Low Country -------3194 100.0 505 100.0 2114 100.0 Total
Depressants No.
%
353 510 289 223 128
23.50 33.92 19.21 14.85 8.52
663 44.06 841 55.94 1258 85.17 217 14.69 2 0.14
341 22.73 93 6.16 141 9.36 255 16.96 56 3.70 136 9.06 185 10.96 85 5.63 168 11.16 64 4.27 1504 100.0
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to Drug Types by Age, Sex, Race, and Region July 1973-June 1974
Drug types Stimulants
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No.
%
Narcotics
No.
%
Hallucinogens
No.
%
Inhalants
No.
%
Other No.
%
Polydrug
No.
%
160 24.90 346 53.71 91 14.09 24 3.66 23 3.58
54 8.51 425 67.57 111 17.65 21 3.34 18 2.86
138 304 36 3 3
28.53 62.97 7.37 0.62 0.52
56 57.14 237 31.04 33 33.67 263 34.45 6 6.12 156 20.43 1 0.51 74 9.69 3 2.55 34 4.39
378 590 193 119 75
27.85 43.60 14.28 8.76 5.51
426 74.80 144 25.20
450 71.77 177 28.23
352 129
73.15 28.85
74 74.62 25 25.32
308 40.25 457 59.75
808 549
59.55 40.45
546 85.64 337 53.92 89 13.97 287 45.92 1 0.16 3 0.39
408 67 5
85.16 13.90 0.94
80 80.71 536 72.11 19 19.29 206 27.62
1082 305
77.15 21.85 0.36
122 19.10 11 1.65 47 7.39 167 26.18 16 2.52 56 8.73 68 10.69 16 2.52
111 14 43 78 22 40 28 9
23.74 2.99 9.09 16.58 4.71 8.55 5.88 1.93
32 5 11 14 3 10 12 0
275 33 143 267 38 115 178 42
20.42 2.45 10.62 19.79 2.82 8.50 13.18 3.12
99 16.81 17 2.88 38 6.45 180 30.56 16 2.72 46 7.81 18 3.06 23 3.90
31.44 5.15 10.82 13.92 2.58 9.79 12.37 0
189 24.6 68 8.88 63 8.17 159 20.72 64 8.30 19 2.42 41 5.36 48 6.28
92 14.38 132 22.41 100 21.28 9 9.28 61 7.91 203 15.04 20 3.40 25 5.35 54.64 56 7.32 55 4.05 -~ 21 3.30 616 100.0 589 100.0 470 100.0 101 100.0 768 100.0 1349 100.0
Fig. 1.
Dysfunctional drug abuse within specific age groups according to drug types
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4
!3
1
8
: *
.. .. .. ..
..
m 0 h 0
.o 0 0 0 \f 0 m 0
N
0
ALCOHOL
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HEROIN
MARIJUANP
W
2
DEPRESSANT!
3
g. J
% a
2
gr,
STIMULANT!
6 0,
g
NARCOTIC
09
W
a
5
HALLUCINOGEN
m
INHALENT
OTHE
PO LYD R l c
0
6
I2
f 0
I:
0,
-4
0
0
m 0
:I
I
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ALCOHOL
HEROIN
MARIJUAM
DEPREWS
STIMULANTS
NARCMICS
HALLUCINOGENS
INHALENS
OMER
POLYORUG
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Table 3 Profile of the Dysfunctional Drug Abuser"
Rank Drug type
I
Marijuana Depressants Stimulants Narcotics Heroin Hallucinogens Inhalants Polydrug Alcohol
WM 18-25 WM 18-25 WM 18-25 WM 18-25 BM 18-25 WM 18-25 WM 18 WM 18-25 WM 36-49
I1
I11
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~
W
=
White, B
=
Black, M
=
male, F
WM 18 W F 18-25 WM 18 BM 18-25 WM 18-25 WM 18 WM 18-25 W.M 18 WM over 49 =
BM 18-25 WF 26-35 WF 18 WF 18-25 WF 18-25 WF 18 WF 18 WF 18 WM 26-35
female.
interstate highway systems. The Berkeley-Charleston-Dorchester Region is located in an area with an interstate highway which connects it with the Central Midlands and Appalachian Regions and with another interstate which runs from Florida to North Carolina. There is a state route that leads to Myrtle Beach where there is a military installation. That area has a network of routes leading to Sumter (another military installation), to North Carolina, and to the Central Midlands Region. There are three military installations in Charleston (an Air Force Base, a Naval Base, and a Naval Hospital) which include a large number of military personnel and their families. There are four educational institutions, 27 junior and senior high schools, and a technical education school in the area which increase the concentration of the youth population.. The ready accessability of the region through land and sea makes it an easy target for the drug traffic. This fact and the very high percentage of the youth age groups have great bearings on the incidents of dysfunctional drug abuse in the area. Heroin incidents in this area are the highest in the state and give indications that there can be a relationship between the geographical location of this region and the high incidents. This point will be taken up later while discussing one of the three studies mentioned above. The Central Midlands Region is located in the center of the state and includes Columbia, the state capitol. A whole network of interstate and state routes passes through Columbia. One route connects it with North Carolina, another route connects it with Atlanta. There is an interstate
ISTIPHAN
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1168
route which comes from Florida and connects with another interstate route passing through Columbia. The third is the Appalachian Region with Greenville and Spartanburg counties having interstate routes connecting them with Georgia and North Carolina as well as with Columbia. The geographical location plus the high concentration of college and high school populations and a developed interstate system make the area vulnerable to drug abuse. South Carolina is located between New York and Florida and is midpoint between South Atlantic and South American nations and the eastern United States. It has seaports and an accessible coastline as well as airports. There is tourist trade and cultural exchange. All these along with the developed interstate system attract drug traffic and encourage its extension to the South Carolina communities.
COMPARISON OF STATE STUDY WITH THREE NATIONAL STUDIES Study # I
The first study to be compared with some of the findings of the state study (Istiphan et al., 1975) is the Assessment of the Diffusion of Heroin Abuse to Medium Sized American Cities. A survey was conducted by the Special Action Office for Drug Abuse Prevention during June 1974, concerning the incidence and prevalence of heroin abuse in 10 American cities (Green et al., 1974). The study was undertaken for two basic reasons: (1) Evaluation of the “ripple theory,” and (2) evaluation of heroin incidence and prevalence methodology. The “ripple theory” states that as time passes, the likelihood of finding epidemic heroin use in large cities (population greater than 300,000)decreases, while the likelihood of finding epidemic heroin use in cities of smaller size increases. The first major goal of the project was to select a sample of 10 medium-sized cities from different regions of the United States and try to determine the status of heroin abuse in each. If the “ripple theory” were correct, one would expect to find current epidemic heroin use at least in some of the cities studied. Several researchers attempted to assess patterns and trends of heroin use at the local level and proposed a number of indicators of the nature and extent of heroin use. These indicators attracted a great deal of interest and criticism, but no attempt was made to assess their applicability in different communities. The second major study goal was to gain ex-
DRUG ABUSE IN SOUTH CAROLINA
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perience in applying the indicators in a wide variety of communities and attempt to assess their utility as measures of heroin use incidence and prevalence. The indicators viewed included the following: a. b. c. d. e. f. g.
Data obtained from heroin addicts entering treatment Hepatitis Data Heroin Overdose-Death Heroin Overdose-Emergencies Law Enforcement Data Data from the University Community Data from the Military Community
The study collected only such data as currently existed in the various communities and no special studies were initiated as part of the project. The following discussion addresses the issue of how useful each of the data sources employed was found to be. A comparison will be made between these findings and those of the state study. a. Treatment Data: The researchers found the relative incidence of heroin use as measured by year of first heroin use reported by treatment of heroin addicts to be the most reliable indicator used. In spite of the numerous objections that were raised regarding its use, the index of heroin incidence, when corrected for lag, appeared to accurately describe the local heroin situation in almost every city visited. In no instance was treatment-derived incidence basically at variance with other data obtained. Combining treatment-based incidence data with the more graphic characteristics of the users has proved to be a remarkably sensitive tool. The researchers found that the application of that technique should substantially reduce the objections initially raised to use of treatment-based information as an indicator of heroin incidence. In the state study, data obtained from the treatment programs showed the highest incidence of heroin. Most of the programs follow a data collection system called CODAP (Client Oriented Data Acquisition Process) which requires information on first use of the drug. In this instance the reliability of the technique will be substantiated or refuted
ISTIPHAN
I170
when time reveals whether the indidence trends projected in each situation actually occur as predicted.
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b.
Hepatitis Data: The state study did not gather data on hepatitis incidence. c. Heroin Overdose-Death: The researchers found their sources of information to be disappointing. Virtually all of the cities visited lacked the framework necessary for drugrelated death data to be of value. They indicated the need for a well-trained medical person involved in the investigation of death of undetermined etiology, an interest in drugs as a cause of death, and the willingness to be frank about deaths of this etiology; there was need for some set of diagnostic criteria by which cases are classified as drug related or not; there was need for reliable toxicology with a keen toxicological screening of all cases in which the cause of death is not obvious, particularly in individuals less than 14 years of age; there was need for a good record-keeping system that gives interested parties access to the data on drug-related death.
In the state study similar difficulties were experienced. Moreover, only 430; of the coroners answered the questionnaires. Among all the drugrelated deaths reported, 2% were recorded as due to heroin. Compared to all the heroin cases reported by agencies in the state, 9”/, were reported by the coroners. d.
Heroin Overdose-Emergencies: With two exceptions, the researchers found that none of the hospitals visited had record-keeping systems that permitted access to records of patients seen in the emergency rooms from heroin overdose (or any drug-related problem, for that matter). Besides the record-keeping issue, it was found that many hospitals were not interested in rendering care to individuals who were drug abusers, and still others actively discouraged such people from seeking care there. It was also felt that those who seek care in a hospital emergency room for a heroinrelated problem run a high risk of being reported to the police and therefore might have been reluctant to seek such help.
In the state study the hospital emergency rooms’ returns were 92%
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compared to returns from other programs. These included all drug incidents. Compared to the reports on heroin cases from other agencies, the emergency rooms reported heroin in 4y4, of their cases. It is possible, as was suspected by the researchers, that people fear to report to the hospital when they have a heroin problem. e. Law Enforcement Data: The relationship between property crime and heroin use incidents, as assessed by a crude comparison of two indices, appears to be erratic at best. I t was found difficult to use the property crime rate as a primary predictor of heroin trends, and it was suggested that the indices would be tested in a community with homogeneous heroin-using populations in order to clarify the illusive relationship between drug use and crime. In the case of the state study, reports do not separate heroin from other cases of narcotic drug abuse. There was a +10.6”;, change in burglary as compared to 19.3:/, in narcotic drug abuse.
+
f.
University Community: With few exceptions, this index was of no value to the researchers as a source of information regarding heroin abuse. It was felt that students did not go to the University Health Services for assistance in dealing with heroin-related illness, or that University Health Officials were unwilling to reveal potentially sensitive information to federal investigators, or there really was not much of a heroin problem on college campuses. They suggested that probably in the future such indices should be deleted.
In the state study, most of the health centers to which survey forms were sent did not respond. No data were gathered directly from the universities themselves. Survey forms, however, were sent to school counselors in the junior and senior high schools. The returns were very low: 20%. Only 27; of the cases were reported as heroin cases. g.
Military Community: The purpose of visiting military facilities was to evaluate any possible relationship between military personnel and members of the adjacent civilian community. There was no evidence to suggest that the civilian heroin situation was the source of drug-abuse problems for military personnel stationed nearby or vice versa
ISTIPHAN
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1172
In the state study, six out of the nine military bases responded to our questionnaire. Eight percent reported heroin cases compared to all such cases reported by other agencies. Some of the bases had a civilian community living near their headquarters. These usually are families of the military men or some of the retired military people themselves. One military base reported meeting the needs of civilians who have association with the base. No effort was made in this study to see whether there was a relationship between the military personnel and civilian population or vice versa. The “ripple theory”: Fact or fantasy? The question is posed by the researchers whether the theory was refuted or validated. The answer is both yes and no depending on the point in time at which the theory was applied. To the extent to which the “ripple theory” puts forth a model of the spread of heroin use, a model based on diffusion of heroin-using behavior from large cities toward small cities as time passes, it would appear that the model has been validated. In five of the cities studied there was a 1-year lag between the nearest major urban center and the study city with regard to peak year of heroin use. The two exceptions were Racine, which peaked in the same year as its nearest major city, Chicago; and Greensboro, in North Carolina, which is located approximately halfway between New York City and Miami, a major distribution corridor for heroin. One could hypothesize that it was a convenient stopover site for those carrying heroin up and down the East Coast. In both these cities, Racine and Greensboro, the peak was in the same year as its nearest major city. In the state study the heroin incidents were very small in the past 2 years. Charleston, however, had the highest incidence of heroin in the state and it is located almost halfway between Miami, Florida, and Greensboro, North Carolina. To the extent that the researchers anticipated finding raging current heroin epidemics in the country’s medium-sized cities, the “ripple theory” was not supported. The researchers concluded that the data would appear to support the validity of the geo-temporal diffusion model of heroin use spread. This diffusion process occurs more rapidly than initially suspected but it does occur both from major urban centers to medium-sized cities, and probably from medium-sized cities to their smaller neighbors. Study # 2
The CODAP Reporting System: The Case of Teen-Age Abusers Admit-
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DRUG ABUSE I N SOUTH CAROLINA
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ted to Treatment (Spillane and Ryser, 1974). The paper highlights a quantitative analysis of the results of the first 6 months of CODAP implementation in the United States. The specific purpose of the paper addressed some of the results derived from an analysis of the client admissions data collected from April through September 1973. In addition, the report included general patterns, areas of concentration, and the broad direction in which future analysis should be pursued. Another feature which will not be considered in this paper deals with a discussion of an important lag variable concept which was devised from the CODAP data. Variables of age, sex, race, and drug types discussed in the national study will be compared with those in the state study. Supplementary information will be added from those agencies that complete CODAP forms.,The national CODAP report showed that there were 75?
