The Associations between Risky Psychosocial Environment, Substance Addiction Severity and Imprisonment: A Swedish Registry Study

Abstract

Objective: Both childhood and adult psychosocial stressors have been identified as links to both increased risk for substance use disorder (SUD) and increased risk of imprisonment. The aim of this retrospective study is to identify, for a sample of 14,914 adults who all were assessed for risky substance use or a SUD, the importance of having a history of psychosocial stressors compared to current addiction severity. The analyses control for age, gender and education on the likelihood of future imprisonment. Method: Baseline Addiction Severity Index data (ASI) were merged with national registry data on prison sentences from 2003 to 2016. In the analysis, a Cox regression was used to study the association between independent variables and the likelihood of future imprisonment. Results: In the regression, five variables showed significant association to increased risk of imprisonment: ASI drugs other than alcohol Composite Score (positive relationship), ASI alcohol Composite Score (negative relationship), age (younger), education (lower) and parental problems with drugs other than alcohol. The factor with strongest association with imprisonment was the ASI drugs other than alcohol Composite Score, which showed the highest HR = 10.63 (3.50–32.31) for women and HR = 5.52 (3.77–8.08) for men to predict the likelihood of imprisonment. Discussion: Research is needed on why individuals with history of psychosocial stressors have a higher likelihood of imprisonment compared to their counterparts. Findings indicate that a high ASI Composite Score for drugs other than alcohol are strong predictors of future criminality and criminal justice system involvement.

Keywords:

• Substance use disorder
• addiction severity index
• imprisonment
• Sweden
• register database study

Introduction

A significant proportion of individuals with substance use disorder (SUD) and histories of addiction commit crime (Bennett & Holloway, 2009; Boden, Fergusson, & Horwood, 2013; Dietze et al., 2013; Fazel, Bains, & Doll, 2006). The use of certain drugs alone is a criminal activity (Fridell, Hesse, Jæger, & Kühlhorn, 2008). Further, research has identified both that crime, in relation to substance use, often occur due to the need to finance drug use, and that there is also an association between certain substance use and engaging in violent crime (Larney & Martire, 2010; Lundholm, Haggård, Möller, Hallqvist, & Thiblin, 2013; Walter, Wiesbeck, Dittmann, & Graf, 2011).

As described above, while the role of substance use in predicting criminal activity has been quite clearly demonstrated by earlier research (Bennett & Holloway, 2009; Boden et al., 2013; Dietze et al., 2013; Fazel et al., 2006; Larney & Martire, 2010; Walter et al., 2011), limited research exists on how life-time stressors, such as having experienced abuse, interact with the relationship between substance use severity and likelihood of future imprisonment after criminal activity.

Hence, the study presented here aimed to identify (among adult individuals all with risky substance use and all assessed for a SUD) whether reporting psychosocial life time traumatic stressors (having resided with parents with a substance use disorder or a psychiatric problem, and having experienced physical abuse, sexual abuse or neglect) were associated with likelihood of imprisonment as an adult. This study also aimed to identify whether addiction severity has a moderating influence on this relationship. Specifically, this study, using Swedish registry data both from the Addiction Severity Index database and the Swedish National Council for Crime Prevention, examined the association between having been sentenced to prison post baseline interview and: (1) having resided with parents with SUD problems; (2) having resided with parents with psychiatric problems; and (3) having experienced abuse, such as mental/emotional-, physical- or sexual abuse. The study then examined the moderating effects of ASI Composite Score (CS) for both alcohol and drugs other than alcohol, and controlled for age, gender and education.

Background

The relationship between active use of alcohol and other drugs and crime is well documented at both the individual and population level (Bennett & Holloway, 2009; Boden et al., 2013; Dietze et al., 2013; Fazel et al., 2006; Larney & Martire, 2010; Lundholm et al., 2013; McClellan & Teplin, 2001; Walter et al., 2011). Persons who use drugs report greater involvement with crime than non-users and are more likely to have criminal records (Pierce et al., 2017). Individuals in Sweden who are both illicit substance users and have a history of involvement in the criminal justice system also have more charges for crimes such as theft or violence, i.e. non-drug offenses (Fridell et al., 2008), whereas alcohol abuse precedes or accompanies a large proportion of sentencing for violent crime (Haggård‐Grann, Hallqvist, Långström, & Möller, 2006; Lundholm et al., 2013; Mcmurran & Gilchrist, 2008). According to information from the Swedish prison and probation service, 60–70% of the clients in Swedish prisons have a substance use disorder. About 40% of those enrolled in these services have illicit drug use offenses as their main crime for imprisonment (SOU 2011:35).

The Swedish criminal justice system consists of probation, custody and prison, where the majority of those enrolled in the criminal justice system are in the probation sector (Kriminalvarden, 2018). The strictest form of punishment in the Swedish criminal justice system is imprisonment (Kriminalvarden, 2016). In the study presented here, our dependent variable was: having been imprisoned any time between the years 2003 through 2016.

Lifetime stressors associated with SUD and criminality

History of maltreatment

Previous research has shown a significant relationship between childhood maltreatment, increased likelihood of problematic substance use (Afifi, Henriksen, Asmundson, & Sareen, 2012; Hamburger, Leeb, & Swahn, 2008; Hussey, Chang, & Kotch, 2006; Shin, Miller, & Teicher, 2013), and criminality (Thornberry, Henry, Ireland, & Smith, 2010). More specifically, results from studies have shown that different forms of childhood maltreatment are associated with an increased likelihood of early age of onset for alcohol or other drugs use (Afifi et al., 2012). In addition to earlier age of onset for substance use, different types of childhood maltreatment have also been linked to earlier regular alcohol use in adolescent samples (Hamburger et al., 2008; Hussey et al., 2006) and increased risk of heavy episodic drinking (Shin et al., 2013). These studies show that there is a clear association between childhood maltreatment and risky alcohol use in young adult years.

The use of substances may also lead to conflict and violence in families, which my increase the risk of physical, mental, or emotional abuse during the childhood (Hjern, Arat, & Vinnerljung, 2014). Studies in the US regarding adolescents and childhood physical abuse showed that abuse history was associated with past-year problematic use of alcohol and other drugs in young adulthood (Lo & Cheng, 2007; Shin et al., 2013). Alcohol has also been found to be a contributing factor for increased risk of incest, child molestation, spousal abuse, and other family violence (Boles & Miotto, 2003). A Swedish study by Lundgren et al. (2013) showed that almost half of all men (47.9%) in this study, assessed for a SUD through ASI, reported a lifetime history of multiple forms of abuse. More precisely, 26.9% of the clients reported having experienced physical abuse at some point during their lives, 4.5% reported that they had a history of sexual abuse, and 40.7% reported having experienced emotional abuse.

Regarding criminality as adults, studies have shown consistent results regarding the association between experience of childhood maltreatment and criminality (Fagan, 2005; Lansford et al., 2007; Thornberry et al., 2010). For example, a US study showed that there is a significant association between experience of childhood and adolescent maltreatment and criminality as adults. This shows that maltreatment, regardless of victims’ age, increases the risk of criminality in adulthood (Mersky, Topitzes, & Reynolds, 2012). In a Danish study, researchers found that different kinds of abuse were associated with criminal behavior, where the respondents that had experienced physical abuse, emotional abuse and physical neglect showed the strongest association for criminality in adulthood (Elklit, Karstoft, Armour, Feddern, & Christoffersen, 2013).

Exposure to parental substance use problems during childhood

Previous research has consistently shown significant associations between SUD within the family and future substance use problems for adolescents and as adults (Andreas & O'Farrell, 2017; Clark, 2004; Park & Schepp, 2015; Stone, Becker, Huber, & Catalano, 2012). Parents with SUD may serve as a role model to their children (Hjern et al., 2014), where parents who use drugs other than alcohol, which are illegal and less socially accepted, increases the risk of their children developing subsequent SUD issues in the future (Järkestig Berggren, Magnusson, & Hanson, 2015).

In different studies (Clark, 2004; Stone et al., 2012) with focus on risk factors related to substance use and problematic use for adolescents and young adulthood, it is evident that there is a clear association for children of parents with an SUD to develop their own substance use problems. Other studies confirm this by showing that addiction to alcohol in families is related to increased risk of alcohol use at earlier age by adolescents (Gruber, Celan, Golik-Gruber, Agius, & Murphy, 2007), and families where drugs other than alcohol are used are associated with an increased risk of substance use by adolescents in these families (Milne et al., 2009). In a Swedish study by Hjern et al. (2014), the researchers found that children whose parents had a SUD during their youth were at increased risk of criminality as an adult, whereas 30% of the study population had been convicted of a crime. Another study regarding adolescents who participated in an outpatient treatment program for substance use showed that about 2/3 had been arrested by the police for criminality, and 1/3 of the study population has been convicted of a crime (Anderberg & Dahlberg, 2014).

Exposure to parental psychiatric problems during childhood

Research regarding parental psychiatric problems during childhood have shown to be associated with increased risk of developing SUD as adults (Alati et al., 2005; Cortes, Fleming, Mason, & Catalano, 2009; Lamis, Malone, Lansford, & Lochman, 2012; Lovejoy, Graczyk, O'Hare, & Neuman, 2000). In a meta-study by Mowbray and Oyserman (2003) regarding risk for developing SUD for children in families with parents who experience psychiatric problems, results showed that these children were at increased risk for developing either an SUD or psychiatric problems, or both, into adulthood. Other studies confirm this by showing an association between earlier onset and higher level of alcohol use for adolescence with maternal depression (Cortes et al., 2009; Lamis et al., 2012). Yet another study shows an increased risk for developing substance use problems is approximately three times higher for a child raised by a depressed mother in comparison to their counterparts who have lived with a non-depressed mother (Weissman et al., 2006).

Research has also shown a relationship between parental psychiatric problems and future criminal behavior for adolescents and adults (Christoffersen, Francis, & Soothill, 2003; Leschied, Chiodo, Nowicki, & Rodger, 2008; Mäki et al., 2003). For example, the study by Christoffersen et al. (2003) showed an increased risk for criminality in adults who have parents with psychiatric problems compared to individuals with parents without a history of psychiatric problems. The study by Mäki et al. (2003) showed a similar result: an increased risk of criminality in adults males of depressed mothers. In a Swedish study (Hjern et al., 2014) regarding adults who, during their childhood, experienced a home environment with parents with psychiatric problems, data show that they are at a twofold increased risk of being convicted of crimes as an adult.

Gender

Research on gender in relation to SUD and treatment has evidenced differences between woman and men regarding their development for SUD and subsequent treatment (Dennis, Scott, Funk, & Foss, 2005; Grella, Hser, & Hsieh, 2003; Grella, Scott, & Foss, 2005; Jiang, Huang, Min, & Hser, 2013; Östlund, Spak, & Sundh, 2004). Studies have in general shown that time with SUD among women was considerably shorter compared to men, and that women often begin with substance use through personal relationships and at later age (Dennis et al., 2005; Grella et al., 2003, 2005). Studies have also shown that women are more likely to have a history of treatment episodes. This can be interpreted as women, in general, are more likely to seek and participate in treatment (Grella et al., 2003; Kang, Deren, & Colón, 2009).

Hence, these studies suggest that it is important to explore whether having experience of maltreatment, experience of family members with substance use problems and experience of family members with psychiatric problems are associated with increased risks of imprisonment in a sample where all respondents engage in risky substance use or have a SUD. Based on our knowledge, there exists a limited number of quantitative studies on the associations regarding experience of risky psychosocial environment, addiction severity, and imprisonment. The study will add to this body of research.

Aim

The study’s first aim was to examine the association between (1) having resided with parents with SUD problems; (2) having resided with parents with psychiatric problems; and (3) having experienced abuse such as mental/emotional-, physical- or sexual abuse with having been sentenced to prison post baseline ASI assessment. The second aim of this study is to identify the moderating variables of addiction severity for both alcohol and drugs other than alcohol, controlling for gender, age, education and having been sentenced to prison post baseline ASI assessment.

Methods

Database

The results presented in this study are based on a multivariate analysis of longitudinal client level assessment data from the Addiction Severity Index (ASI) database (McLellan et al., 1992), registry data from the Swedish criminal justice registry (BRA), and data from the Death registry (to control for mortality being the reason a client is not in the criminal justice registry). With respect to the ASI database, the ASI assessment tool is used nationwide in Sweden to identify risky substance use and substance use disorder. The Swedish National Board of Health and Welfare, which oversees all health and social services, oversees the municipal social care system where the majority of SUD assessments take place. Individuals are either referred there or are self-referred due to risky substance use or substance use disorder. These municipal offices also provide a range of interventions, such as brief interventions, outpatient treatment, inpatient treatment, referral to health and employment services, financial support and housing support. Since beginning of the 1990s, the National Board of Health and Welfare (NBHW) has promoted the implementation of the ASI as the main assessment tool for clients with risky substance use and substance use disorder.

The ASI is a semi-structured interview and based on a multi-dimensional perspective regarding substance use severity and related health and social problems, with all questions based on self-reported answers (McLellan, Cacciola, Alterman, Rikoon, & Carise, 2006). The ASI psychometric properties have been tested extensively at a global level and with a range of different populations. This instrument demonstrates good to excellent reliability and validity. Some findings, however, suggest varied reliability of the ASI mental health CS (Lundgren & Krull, 2018; Mäkelä, 2004; McLellan et al., 1992; Nyström, Andrén, Zingmark, & Bergman, 2010; Pankow et al., 2012; Padyab et al., 2018; Samet et al., 2007). Regarding registry data, Sweden with its long history of collecting data and the use of unique social security numbers, the population- and health data registers gives a opportunities to conduct research by using data on high quality and high reliability (SOU 2012:36).

Study population

The study population includes adults (18 years of age and older) with complete demographic data (n = 14,914) who were assessed through the use of ASI for risky substance use or a substance use disorder between 2003 and 2016 in 65 Swedish municipalities. This sample represent about 35–40% of adults assessed through the use of ASI in Sweden for the time period studied. The study received Institutional Review Board ethics approval from both the National Bureau of Health and Welfare (NBHW) and the Regional Ethical Review Board at Umeå University.

Independent variables

Age, reported at ASI baseline, was measured through a continuous variable. Level of education at baseline was also measured by a continuous variable, based on the total number of years of education. The gender variable was sorted out by a dichotomous variable divided into female and male. Addiction severity was measured through the ASI Composite Scores (CS) for both Alcohol and Drugs other than alcohol. Each of the CS measures focused on use, how bothered the client felt by problems arising from alcohol and/or drug use, and how important the client felt it was to get help to address those problems. These CS (aggregated points) provide general measurements of the client's situation within each problem area in the ASI-interview. The higher the points, the more severe the client’s problems/needs are in each area.

The variables regarding history of parental psychiatric/substance use problems were measured through three different dichotomous variables (yes or no): parental alcohol problem, parental problem with drugs other than alcohol and parental psychiatric problem. Variables for measuring history of abuse was captured by three dichotomous variables (yes or no): if the individual ever experienced emotional abuse, if they ever experienced physical abuse, and if they ever experienced sexual abuse.

Dependent variable

The dependent variable is dichotomous, describing whether a person was sentenced to prison any time after the ASI-baseline interview (yes or no).

Statistical analysis

Univariate descriptive statistics were used to describe the research sample. Next, bivariate analyses were conducted using chi-square and t-tests to examine the relationship between each independent variable and the dependent variable. The analysis was stratified by gender, since previous research on gender and SUD and treatment for SUD has shown differences between woman and men regarding their development for SUD and subsequent treatment (Grella et al., 2005; Jiang et al., 2013; Kang et al., 2009; Östlund et al., 2004). To investigate whether baseline SUD problem and history of parental psychiatric/substance use problems were associated with imprisonment post baseline, we used Cox proportional hazards regression modeling (Cleves, Gould, Gould, Gutierrez, & Marchenko, 2008) to estimate adjusted hazard ratios (HR) with 95% confidence intervals. Significant variables at the bivariate level were used in a multivariate hierarchical Cox proportional hazard model in three blocks. This model was used to assess the predictive value in history of parental substance use problems (first block), history of physical abuse (second block) and sociodemographic variables and substance use severity (third block).

Clients were followed until date of first imprisonment, or the latest date for which they were known to be alive through December 31, 2016, whichever came first (we did have access to mortality registry data for all individuals in the sample). All analyses were performed using STATA version 15.1.

Results

Table 1 shows the general characteristics of the study population. The study included 14,914 clients assessed for a SUD. Of which, 2,184 (15%) had been sentenced to prison in the time period 2003 and 2016. Mean ± sd age was 38 ± 14 years for women and 39 ± 14 years for men. On average, the sample had completed 11 years of education with no differences between women and men. This sample was unevenly split by gender, as 10,574 (71%) were men.

Table 1. Description of the population.

Variable	Female (N = 4 340)	Male (N = 10 574)	Total (N = 14 914)
Age (mean ± SD)	38 ± 14	39 ± 14	38.9 ± 14
Education (mean ± SD)	11.5 ± 2.8	11.2 ± 2.7	11.2 ± 2.8
Primary drug
ASI composite scores (mean ± SD)
Alcohol	0.34 ± 0.3	0.34 ± 0.3	0.34 ± 0.3
Narcotic	0.12 ± 0.14	0.13 ± 0.15	0.13 ± 0.14
Alcohol problem mother (%)
Yes	26	17	19
No	74	83	81
Narcotic problem mother (%)
Yes	10	6	7
No	90	94	93
Psychiatric problem mother (%)
Yes	29	16	20
No	71	84	80
Alcohol problem father (%)
Yes	47	40	42
No	53	60	58
Narcotic problem father (%)
Yes	12	10	11
No	88	90	89
Psychiatric problem father (%)
Yes	19	13	15
No	81	87	85
Emotional abuse (%)
Yes	70	40	49
No	30	60	51
Physical abuse (%)
Yes	60	33	41
No	40	67	59
Sexual abuse (%)
Yes	34	5	13
No	66	95	87

The study population reported a relatively high degree of social stressors related to parental psychiatric/substance use problems. Nineteen percent (19%) reported that their mother had alcohol problems, seven percent (7%) reported she had problems with drugs other than alcohol and twenty percent (20%) stated she had psychiatric problems. Women reported a higher level of risk exposure compared to men (see Table 1). Regarding factors of psychiatric/substance use problems related to their father, forty-two percent (42%) of the clients reported that their father had alcohol problems, eleven percent (11%) reported their father having problems with drugs other than alcohol, and fifteen percent (15%) responded their father having psychiatric problems. Also in this case, women reported a slightly higher level of risk exposure compared to men (see Table 1).

Regarding history of social stressors related to different kinds of abuse, forty-nine percent (49%) of the clients reported that they have had experienced emotional abuse, forty-one percent (41%) that they experienced physical abuse, and thirteen percent (13%) reported experience of sexual abuse. Women reported two to six times more experience of abuse than men (see Table 1).

Bivariate statistical analysis

The bivariate statistical analysis evidenced (see Table 2) that a number of variables were significantly associated with imprisonment. Specifically, it showed that individuals who had been imprisoned were younger, had less education, lower ASI alcohol scores and higher ASI drugs other than alcohol scores compared to their counterparts who had not been in prison. Also, those who reported having parents having problems with drugs other than alcohol (mother and/or father) and those who reported having experienced physical abuse were more likely to end up in prison post-ASI assessment. This was markedly higher among men compared to women. To note, there was no significant relation between parental psychiatric problem and future imprisonment.

Table 2. Distribution of post-ASI imprisonment (N = 14 914) by baseline characteristics.

	Imprisonment
Variable	Female		Male
Gender	Imprisonment No	Imprisonment Yes	Imprisonment No	Imprisonment Yes
Age	38 ± 14	35 ± 12***	40 ± 14	34 ± 11***
Education (Year mean ± sd)	11.6 ± 2.8	10.1 ± 2.5***	11.3 ± 2.7	10.4 ± 2.5***
Primary drug
ASI composite scores (mean ± SD)
Alcohol	0.35 ± 0.3	0.24 ± 0.3***	0.35 ± 0.3	0.27 ± 0.3***
Narcotic	0.12 ± 0.1	0.18 ± 0.2***	0.12 ± 0.1	0.18 ± 0.2***
Alcohol problem mother (%)
Yes	93	7	80	20
No	95	5	83	17
Narcotic problem mother (%)
Yes	90	10***	75	25***
No	95	5	82	18
Psychiatric problem mother (%)
Yes	95	5	83	17
No	94	6	82	18
Alcohol problem father (%)
Yes	94	6	81	19
No	94	6	83	17
Narcotic problem father (%)
Yes	91	9***	76	24***
No	95	5	83	17
Psychiatric problem father (%)
Yes	95	5	82	18
No	94	6	82	18
Emotional abuse (%)
Yes	94	6	81	19
No	94	6	82	18
Physical abuse (%)
Yes	93	7**	80	20**
No	96	4	83	17
Sexual abuse (%)
Yes	94	6	84	16
No	94	6	82	18

**p < .01, ***p < .001 in comparison to those without imprisonment.

Cox proportional hazard regression

As Tables 3 and 4 shows, eight variables in three different models were used in the Cox proportional hazard regression model. The first model included three variables with a focus on the parental situation regarding drugs other than alcohol, only mother, only father, or both mother and father. Of these, for women, only if both mother and father had problems with drugs other than alcohol the model showed increased likelihood of imprisonment. Regarding men, all three variables (mother’s problem, father’s problem, and both mother and father’s problem with drugs other than alcohol) were significantly associated with increased likelihood of imprisonment. The second model of the Cox regression added the variable of physical abuse. When these four variables (mother’s, father’s, both mother and father’s problem with drugs other than alcohol and physical abuse) were included in the regression, it still shows that for women, if both their mother and father had problems with drugs other than alcohol and if the respondent ever experienced physical abuse, the variables were significantly associated with increased likelihood of having been imprisoned at any point between 2003 and 2016. For men, all four variables (mother’s or father’s problem with drugs other than alcohol, both mothers and father’s narcotic problems and physical abuse) showed significant relationships to an increased risk for imprisonment (Model 2, Table 4). Having both mother and father with problem with drugs other than alcohol was associated with 72% increased likelihood in imprisonment.

Table 3. Cox proportional hazard regression to association between childhood factors and post-ASI imprisonment (N = 4340).

Variable	Model I HR (95% Cl)	Model II HR (95% Cl)	Model III HR (95% Cl)
Gender - Female
Parental narcotic problem
Only mother	1.49 (.88–2.54)	1.45 (.85–2.47)	1.09 (.56–2.09)
Only father	1.26 (.76–2.08)	1.20 (.73–1.99)	.83 (.44–1.56)
Both mother or father	3.36 (2.19–5.18)***	3.20 (2.07–4.94)***	2.26 (1.35–3.76)**
Physical abuse		1.44 (1.06–1.95)*	1.12 (.79–1.59)
ASI CS narcotic			10.63 (3.50–32.31)***
ASI CS alcohol			.36 (.19–.68)**
Education			.86 (.80–.91)***
Age			.88 (.99–1.02)

*p < .05 **p < .01 ***p < .001.

Model I: Crude.

Model II: Model I + Physical abuse.

Model III: Model I + Physical abuse + Age + ASI composite scores for Alcohol and Drug + Education.

Table 4. Cox proportional hazard regression to association between childhood factors and post-ASI imprisonment (N = 10 574).

Variable	Model I OR (95% Cl)	Model II OR (95% Cl)	Model III OR (95% Cl)
Gender - Male
Parental narcotic problem
Only mother	1.40 (1.10–1.79) **	1.36 (1.06–1.75)*	1.09 (.82–1.45)
Only father	1.43 (1.21–1.70) ***	1.38 (1.16–1.64)***	.98 (.81–1.19)
Both mother and father	1.79 (1.39–2.31) ***	1.72 (1.34–2.23)***	1.18 (.89–1.57)
Non
Physical abuse		1.15 (1.04–1.28)**	1.05 (.94–1.18)
ASI CS narcotic			5.52 (3.77–8.08)***
ASI CS alcohol			.64 (.52–.79)***
Education			.90 (.88–.92)***
Age			.98 (.98–.99)***

*p < .05 **p < .01 ***p < .001.

Model I: Crude.

Model II: Model I + Physical abuse.

Model III: Model I + Physical abuse + Age + ASI composite scores for Alcohol and Drug + Education.

In the third model of the Cox regression, four more variables were added: ASI drugs other than alcohol CS, ASI alcohol CS, years of education and age. We used ASI composite scores for drugs other than alcohol and alcohol as indicators for drug severity. Since imprisoned clients had significantly higher drug severity in bivariate models, we aimed to assess the moderating effect of drug severity on the association between psychosocial lifetime stressors and imprisonment as an adult. To respond to this research question, we performed hierarchical Cox proportional hazard modeling using drug severity as an additional predictor (Model 3) and compared the hazard ratios with models without moderating variables (Model 2). The findings showed that drug severity could decrease the explanatory impact of life time stressors, as a result of reduced hazard ratio from HR = 3.20 in Model 2 to HR = 2.26 in Model 3. For women, there were significant relationships between the ASI drugs other than alcohol CS (positive relationship), ASI alcohol CS (negative relationship), years of education and if both mother and father had problems with drugs other than alcohol. For men, there were significant relationships between the ASI drugs other than alcohol CS (positive relationship), ASI alcohol CS (negative relationship), age (younger) and education (lower), that showed a higher likelihood for imprisonment. Note that the factor that was most strongly associated with sentencing to prison was the ASI drugs other than alcohol CS (for both women and men), which in the regression model showed the highest HR = 10.63 (3.50–32.31) for women and HR = 5.52 (3.77–8.08) for men to predict the likelihood of imprisonment (Tables 3 and 4).

Discussion

This study identified, for a sample of 14,914 adults who were all assessed for risky substance use or a SUD, the relative importance of having a history of psychosocial stressors (having resided with parents with a substance use disorder or psychiatric problems and having experienced physical abuse, sexual abuse or neglect) compared to current addiction severity, controlling for age, gender and education on the likelihood of future imprisonment. In summary, the study identified, at the multivariate level, that for women, having had a mother and a father who used drugs other than alcohol was associated with a 2.3 times higher likelihood of having been imprisoned and having a higher ASI drugs other than alcohol CS was associated with having a 10.7 times higher likelihood of having been imprisoned any time between 2003 and 2016. Additionally, having a lower ASI alcohol CS and lower levels of completed education were also significantly associated with being imprisoned sometime from 2003 to 2016. For men, the study identified, at the multivariate level, that having a higher ASI drugs other than alcohol CS was associated with having a 5.5 times higher likelihood of having been imprisoned between 2003 and 2016. Additionally, having a lower ASI alcohol CS, having lower levels of completed education and being younger were also significantly associated with being imprisoned sometimes between 2003 and 2016. Therefore, it is important to highlight that addiction severity to drugs other than alcohol (ASI CS), having less severe addiction to alcohol (ASI CS), and having lower levels of education remain static predictors of imprisonment across gender.

In line with previous research, the findings of this study support findings from both US studies (Mersky et al., 2012) and a Danish study (Elklit et al., 2013) which show that having experienced abuse in the past is associated with future criminal behavior/imprisonment. Additionally, this study’s research builds on previous research showing that parental substance use may impact their children’s future substance (Clark, 2004; Milne et al., 2009; Stone et al., 2012). Because substance use severity was a predictor of time spent in prison in this sample, we see that respondents whose parents had a SUD were more likely to be involved in the criminal justice system (Anderberg & Dahlberg, 2014; Hjern et al., 2014). The finding that higher age can be interpreted as protective for individuals at risk for imprisonment confirms existing research (Carlsen, Steingrimsson, Sigurdsson, Sigfússon, & Magnússon, 2017). The results of this study do not confirm that children who have experienced parents with psychiatric problems having an increased risk of imprisonment as adults.

Implications

One finding from our study, with both policy and clinical implications, is that having a history of psychosocial stressors (having resided with parents with a substance use disorder and having experienced physical abuse, sexual abuse or neglect) was associated with imprisonment as an adult (Table 2). Hence, the child welfare system is an important starting point for efforts to prevent future social and criminal justice problems in adulthood. The group of children and adolescents living under psychosocial family related stressors need to be protected by society through different authorities that comes into contact with the families with substance use or psychiatric problems. Hence, these children need high access and priority to different interventions from school, social services, and childhood psychiatric clinics. It is possible that effective strategies to reduce psychosocial stressors in the general population may also yield a reduction in SUDs.

When adults and families are in need of support or interventions, such as SUD-treatment, financial support, and/or housing support, it is important to highlight if there are any children or adolescents in the home that are also at risk. Therefore, it is important to take into account that family related psychosocial stressors are associated with increased risk of risky substance use into adulthood (Afifi et al., 2012; Clark, 2004; Gruber et al., 2007; Milne et al., 2009; Stone et al., 2012), so it is important and necessary for clinical investigation that includes whole family system.

A second implication is in the differences between how women and men (Table 1) assess their history of psychosocial stressors, such as family related problems (alcohol or drug use other than alcohol or psychiatric problems by parents) and history of abuse (emotional, physical or sexual abuse), where women show a significantly greater self-assessed history of psychosocial exposure among clients with risky substance use or a SUD in comparison with men. Regarding psychosocial stressors, research shows that early experiences of insecurity, stress and trauma are factors that are much more prevalent among women with SUD compared to their counterparts (Östlund et al., 2004). Examples of unfavorable circumstances where individuals are at risk of developing an addiction, are that they are born and raised in a family where a family member has substance use disorder or psychiatric problem. Growing up in a context where substance use disorder and psychosocial problems exist can lead to experiences of stress. Further, experience of exclusion and guilt are common for children and adolescents in families with a SUD (Östlund et al., 2004), which can lead to personal problems and risk of development of their own addiction.

This is important knowledge for both clinical staff conducting assessment for SUD and staff in the criminal justice system to be aware of. Research shows that for women with substance use disorder, a gender segregated treatment provides the opportunity for better results in both reduced substance use and improved quality of life compared to standard treatment that includes both genders (Moos, Moos, & Timko, 2006). Another study showed that positive treatment outcomes for women's SUD treatment were that they should have access to, for example, childcare, social support, psychiatric treatment, skills training and job rehabilitation (Ashley, Marsden, & Brady, 2003). Choice of treatment for individuals with a SUD is often governed by several factors: that the treatment method should be evidence-based, accessible, and close in distance (i.e. the ability to participate and access the treatment). Therefore, an interpretation of our study can be that a factor that always should be taken into account for women with a SUD is the ability to participate in gender-specific treatment programs.

Regarding the population of focus in this study, the results (Tables 3 and 4) most likely relate to Swedish policy regarding drugs other than alcohol. Of course, a key reason use of drugs other than alcohol is so strongly related to imprisonment is because substance use is illegal in Sweden. Something important to note is that police in Sweden are actively encouraged to apprehend individuals who use drugs other than alcohol; because substance use other than alcohol is criminalized in Sweden, those with SUD are handled by the criminal justice system (Käll, 2009; Tham, 2005).

Regardless of this, it is of great importance to use the criminal justice system and time spent in prison as an opportunity to start treatment for substance use disorders. In many cases, treatment also needs to be completed after the prison episode has ended. Hence, it is important that efforts started during prison are given the opportunity to continue after release, including both psychosocial focused interventions and medication for addiction treatment (MAT). The interventions given during the time in prison should not be considered as a single and isolated effort. In order to facilitate the reintegration of the individual in society, continued efforts are often required after the termination of the prison sentence. This requires a collaboration between the criminal justice system and other authorities, such as social services and the health care system.

As mentioned above, in the execution of the prison sentence, the criminal justice system has the opportunity to provide support and initiate a motivational intervention and treatment regarding clients with substance use problems and addiction. The total resources put forward in those efforts should be taken care of in an effective manner for both individual and societal level benefits. An effective relapse prevention effort and a planned release preparation requires an effective and well-functioning interaction between the criminal justice system and relevant authorities, such as the municipal social services, the health care system, and the labor market to facilitate the clients’ re-adapting to society without the need for narcotics nor criminalized acts.

Limitations

First, reader should be aware of that this study is based on self-reported data on history of psychosocial stressors, such as having resided with parents with a substance use disorder or a psychiatric problem, and having experienced physical abuse, sexual abuse or neglect. As a next step, studies need to use registry data, such as The National Board of Health and Welfare's (NBHW) patient register, on history of psychosocial stressors and abuse.

Second, another limitation to the results of the study is regarding the heritability of SUD; where we do not have medical records to verify parental SUD or psychiatric history. And further limitations are that all individuals in the BRA-database include those who have already received their verdict. It does not include anyone who is under investigation or pending their sentence.