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Nitrite inhalant abuse in antisocial youth: prevalence, patterns, and predictors.

Nitrite inhalants are effective vasodilators and have been used in the treatment of chest pain for more than 100 years (Butler 2006). During the 1960s and 1970s, nitrite use became popular among some nightclub attendees and men who have sex with men (MSM) (Sansweet 1977). Although abuse of nitrite inhalants continues to be a public health concern in North America and Europe, relatively little is known about the characteristics of illicit nitrite users and the patterns and correlates of their nitrite use. It is, however, well established that some users believe the drug enhances certain social and sexual experiences (e.g., French & Power 1998). Though nonprescribed use of nitrites is legally prohibited in the United States, nitrites are readily available for purchase on the World Wide Web, where they are distributed in small vials and marketed under product descriptions such as "video head cleaner," "room odorizer," "leather cleaner," and "liquid aroma" (Romanelli et al. 2004).

Recent nationally representative surveillance data from the 2006 Monitoring the Future (MTF) survey indicate that 1.2% of 12th grade students in the U.S. have used nitrites (Johnston et al. 2007). Wu and colleagues (2005) reported similar findings, estimating that 1.5% of the 36,859 12-to-17 year-olds participating in the 2000/2001 administrations of the National Household Survey on Drug Abuse had used nitrites.

Nitrite inhalant abuse is associated with a number of seriously adverse health and social outcomes, including methemoglobinemia (Modarai et al. 2002; Stambach et al. 1997), hemolysis and hemolytic anemia (Graves & Mitchell 2003; Stalnikowicz, Amitai & Bentur 2004), temporary and irreversible loss of vision (Pece et al. 2004; Fledelius 1999), acrocyanosis (Hoegl, Poppinger & Rocken 1999), altered gene expression and impaired tumor surveillance mechanisms (Tran et al. 2006, 2003; Soderberg 1999), suicide attempts (Botnick et al. 2002), accidental fatal drug overdoses (O'Driscoll et al. 2001), and risky sexual behaviors (Lampinen et al. 2007).

Recent findings suggest that nitrite use and its sequelae are endemic in some population subgroups. An important literature has accrued documenting high rates of nitrite use among some MSM (e.g., Lampinen et al. 2007; Hidaka et al. 2006; Koblin et al. 2003; Thiede et al. 2003; Wheater et al. 2003; Binson et al. 2001). Other reports have referred to nitrite "poppers" as the "cocaine of poor people" (Schmitt & Bogusz 1989) and identified elevated rates of nitrite use among youth with mental health and substance use disorders (e.g., Wu et al. 2005). However, estimates of nitrite use among adolescents are generally based on surveys that excluded antisocial youth in residential rehabilitative care, a population known to have high rates of volatile solvent inhalation (e.g., Howard et al. 2008; Howard & Jenson 1999). Although one report of the British Home Office identified high rates of nitrite use among juvenile offenders (Hammersley, Marsland & Reid 2003), we are not aware of any prior research focusing specifically on nitrite use by youth in residential care for antisocial behavior.

Thus, this report is among the first to assess the use of nitrite inhalants among a well defined and comparatively large sample of antisocial adolescents. Specific aims of the study were to: (1) describe the prevalence and patterns of nitrite use in a state population of incarcerated youth and (2) identify factors that distinguish adolescent nitrite users from nonusers in bivariate and multivariate analyses.

METHODS

Study Sample

Residential rehabilitation services of the Missouri Division of Youth Services (DYS) are provided at 27 facilities statewide. Facilities range in size from eight to 102 beds. DYS is the legal guardian of residents committed to its care by the state's juvenile courts. The DYS client population is representative of incarcerated youth nationally with regard to the age, gender and number of state youth incarcerated per 100,000 adolescents (Sickmund 2002).

The four DYS regions were targeted for interviewing in sequential order. Residential facilities within each region were interviewed sequentially. All residents at a facility were recruited for participation at the time interviewing at that facility commenced. The recruitment protocol ensured that no youths who had completed the interview at one DYS facility were subsequently reinterviewed at another DYS facility. Interviewing was completed over a three-month period in 2003. Youth completed the interview in one 30 to 90 minute session, the length depending principally on the respondent's inhalant use history. Youth were allowed short breaks during the interview if they became fatigued, but remained under the observation of DYS staff and project interviewers consistent with DYS policy.

All current DYS residents (N = 740) were eligible to participate in the study. Ten youths were on furlough at the time of interviewing and two youths were transferred to another facility while interviewers were at the facility, but before they could be interviewed. Of the 728 youth available to interview, all agreed to participate. However, five interviews were discontinued; four youth displayed signs or reported symptoms of psychosis and one youth chose not to continue. The 723 youth who completed the interview constituted 98% of DYS residents at the time interviewing was conducted, 99% of residents available for interviewing, and approximately 55% of youth committed to DYS care in the prior year. Thus, the present study is virtually a census of the population of DYS residents at the time the study was undertaken and a large, representative sample of DYS annual residents.

Interviews were conducted by 15 graduate social work student interviewers; seven core interviewers completed 530 (73%) interviews. Interviewers completed an intensive one-day training session and an interview editor was on-site at each facility as youth were interviewed to minimize interviewer errors. Interviews were conducted in large rooms at each facility that provided private areas where confidential one-on-one interviews could be conducted. Before each interview commenced, interviewers ensured that they and the respondent were comfortable that their responses could not be overheard. Youth signed informed assent forms and were provided with $10.00 to their facility monetary accounts (and a receipt for such) for completion of the interview. The informed assent form and interview protocol provided residents with detailed information about the study, the name and contact telephone number for a nonstudy or university-affiliated advocate who they could call for more information about the study (DYS agreed to allow youth to use telephones for this purpose at any time during business hours), assured youth they were not required to participate, could cease participation in the interview at any time, and that their legal status would not be affected whatsoever by their participation or nonparticipation in the study. Because DYS was the legal guardian of all youth, DYS provided formal consent for youths to participate in the study.

The informed consent and study protocols were approved by the Missouri DYS Institutional Review Board and the Washington University Human Studies Committee Institutional Review Board (operating in strict accordance with the governing regulations for research on prisoners); the project was officially certified by the federal Office of Human Research Protection, and was granted a Certificate of Confidentiality by the National Institute on Drug Abuse. All youth were provided with a thorough description of their privacy rights, a copy of a Washington University brochure, "Your Privacy Matters," and a copy of the informed assent agreement.

Measures

All youth completed the Volatile Solvent Screening Inventory (VSSI), an approximately 45-minute interview assessing demographic characteristics, medical history, lifetime/annual use of 65 inhalants, other drug use and substance-related problems, current psychiatric symptoms, thoughts of suicide/actual suicide attempts, trauma history, antisocial traits and criminal behavior (Howard et al. 2008). The following VSSI measures were used in the analyses reported below.

Demographic factors. Gender, age, self-reported racial status, grade (current or last completed), family receipt of public assistance, and geographical area of family residence (i.e., urban, suburban, small town, rural) were recorded for each youth.

Medical history. Respondents were asked to indicate whether (yes or no) they had ever experienced a head injury that caused a period of extended unconsciousness, been diagnosed with a mental disorder by a psychiatrist or other doctor, heard voices of people who were not actually there, had suffered from a major illness or injury around the time of their birth, or had kidney disease, hormonal disorders, blood disorders, or neurological problems (e.g., brain infection, tumor, or disease). Respondents were also asked to report all current medications they were taking. Due to confidentiality and logistical concerns, youths' self-reports of medical conditions and medication use were not validated against official medical records, parental reports, or agency data.

Nitrite use. Respondents were asked three nitrite-related questions: 1) "Have you ever inhaled or 'huffed' amyl nitrite (i.e., 'poppers' or 'snappers') through your nose or mouth in an effort to get high?"; 2) "Have you ever inhaled or 'huffed' butyl nitrite (e.g., 'Rush,' 'Locker Room,' 'Medusa,' 'Bolt,' 'Bullet,' or 'Climax') through your nose or mouth in an effort to get high?"; and 3) "Have you ever inhaled or 'huffed' any other product containing amyl or butyl nitrite through your nose or mouth in an effort to get high?" Most youth were familiar with the term "huffing" and few respondents evidenced any difficulty in understanding the meaning of the inhalant use questions. Interviewers were carefully trained to record only nitrite use occurring in conjunction with an acknowledged intention to get high. Any youth answering affirmatively to one or more of the three nitrite use questions was classified as a lifetime nitrite user.

For each of the three nitrite questions respondents answered "yes" to, they were asked to report whether they actually got high (yes or no) when they used the nitrite product. Lifetime nitrite users were also asked to report the number of days they used nitrites in their lifetime (1 = <5, 2 = 5 to 10, 3 = 11 to 99, 4 = [greater than or equal to] 100), the frequency of their nitrite use in the year preceding incarceration (0 = once, 1 = two to four times, 2 = five to 10 times, 3 = once a month, 4 = every two to three weeks, 5 = once a week, 6 = two to three times a week, 7 = once a day, and 8 = two to three times a day), and to indicate which one of five modes of nitrite use (i.e., spray the substance directly into your nose or mouth; sniff or inhale from a plastic bag placed over your nose, mouth, or head; sniff or inhale from a cloth or clothing saturated with the substance and placed over your nose, mouth, or head; sniff or inhale from a container, such as a jar or bottle or balloon filled with gas; other) best reflected how they most often used nitrites.

Other substance use: Use of 20 additional categories of psychoactive substances was assessed. For each psychoactive agent assessed, youth reported whether or not they had ever used the drug (yes or no), their age at first use of the drug, the number of days in their lifetime (1 = <5, 2 = 510, 3 = 11-99, 4 = [greater than or equal to] 100) they had used the drug, and their frequency of use of the drug in the year prior to incarceration (0 = once, 1 = two to four times, 2 = five to 10 times, 3 = once a month, 4 = every two to three weeks, 5 = once a week, 6 = two to three times a week, 7 = once a day, and 8 = two to three times a day).

Substance-related problems: Lifetime substance-related problems were assessed with the eight-item Alcohol/Drug Use Scale of the Massachusetts Youth Screening Instrument--2nd Version (MAYSI-2; Grisso & Barnum 2000), which was developed for use with juvenile justice populations. Youth responded "yes" or "no" to questions about whether they had ever been drunk or high at school, had used alcohol and drugs at the same time, had ever been so drunk or high they couldn't remember what happened, used alcohol or other drugs to help them feel better, had gotten into trouble while high or drinking, (if yes) whether or not that trouble had been fighting, had done anything they wished they hadn't while drunk or high, or had their parents think they drink too much. Scores could range from 0 to 8. Grisso and Barnum (2000) found the scale to be internally consistent ([alpha] = .86) in their norming sample; the [alpha] coefficient in this study was .83.

Suicidal ideation and attempts. Youth completed the 5item MAYSI-2 Suicide Ideation scale, which requires youth to respond "yes" or "no" to questions assessing whether or not they have ever wished they were dead, have felt like life was not worth living, have felt like hurting themselves, have felt like killing themselves, and have ever given up hope for their life. Grisso and Barnum (2000) reported a [alpha] reliability of .83; the [alpha] coefficient in this study was .91. Youth were also asked to report whether or not they "had ever actually tried to kill themselves" (yes or no).

Lifetime trauma. All respondents completed a four-item Traumatic Experiences scale adapted from the MAYSI-2 ([alpha] = .69 in the current study). Youth were asked to indicate whether or not (yes or no) they had ever seen someone severely injured or killed in person (not in the movies or on TV), had a lot of bad thoughts or dreams about a bad or scary event that happened to you, had ever been badly hurt, or been in danger of getting badly hurt or killed, and had ever in their whole lives had something very bad or terrifying happen to them.

Current psychiatric symptoms. All respondents completed the Brief Symptom Inventory (BSI; Derogatis 1993), consisting of 53 items assessing the extent to which youth were "bothered or disturbed" (0 = not at all; 4 = extremely) by a variety of thoughts or feelings "over the last seven days including today." The BSI yields a global index of overall current psychiatric distress (possible range = 0 to 212, [alpha] = .96 in current study) and scores for nine primary symptom dimensions: somatization, obsessive-compulsive, interpersonal sensitivity, depression, anxiety, hostility, phobic anxiety, paranoid ideation, and psychoticism. Raw scale total scores were used; subscale [alpha] reliabilities ranged from .70-.83.

Antisocial traits. Study participants completed the 56-item Psychopathic Personality Inventory Short-Version (PPI-SV; Lilienfeld & Andrews 1996). Youth were asked to decide to what extent each of the personality characteristics described in each statement were false or true as applied to them (1 = false, 2 = mostly false, 3 = mostly true, 4 = true). Total scores could range from 56 to 224 ([alpha] = .76). The eight subscales of the PPI-SV include Machiavellian Egocentricity, Social Potency, Coldheartedness, Carefree Nonplanfulness, Fearlessness, Blame Externalization, Impulsive Nonconformity, and Stress Immunity ([alpha]'s = .55-.73).

Delinquent behavior. The Self-Report of Delinquency (SRD; Elliott, Huizinga & Menard 1989) was used to assess how many times in the year before they were incarcerated youth engaged in seven nonviolent and 10 violent crimes. Responses could range from 0 (never) to 8 (two to three times a day) for each item. Total SRD scale scores could range from 0 to 136 ([alpha] = .84), while the ranges of possible scores were 0-56 ([alpha] = .81) and 0-80 ([alpha] = .73) for the nonviolent and violent offense subscales, respectively. Youth also reported the age at which they first committed a criminal offense, had contact with the police, and were first referred to juvenile court. A four-item victimization index ([alpha] = .76) was used to assess frequency of personal experiences of criminal victimization in the year prior to incarceration. The response format for the victimization scale was identical to that used for the SRD. Total victimization scores could range from 0-32.

Data Analysis

Bivariate and adjusted comparisons of lifetime nitrite users and nonusers were conducted using [chi square] and logistic regression for categorical variables and t-tests for continuous variables. Homogeneity of variance assumptions were tested and degrees of freedom adjusted as appropriate. Effect sizes were computed and presented as either odds ratios or Cohen's d (Cohen et al. 2003) depending upon the analysis.

RESULTS

Characteristics of Incarcerated Youth

Table 1 provides a description of the study sample. Respondents averaged 15.5 (SD = 1.2) years of age and were racially diverse. Most participants were male and a substantial minority (40%) reported that their families currently received public assistance.

Histories of head injuries and mental illness were reported by many youth. A substantial minority (42%) of youth was currently taking prescribed psychotropic medication. More than one-third of the sample (37%) was taking medication for attention deficit-hyperactivity disorder; 23% reported current use of antidepressants, and 12% and 10%, respectively, were taking mood stabilizers and antipsychotics. Most DYS residents (83%) had been incarcerated for one year or less; 12% had served one to two years, and 4% had served two to five years.

Lifetime Nitrite Use

Prevalence. The lifetime prevalence of nitrite use in the total sample was approximately 2%. The 12 nitrite users consisted of eight males and four females. Thus, slightly more than 1% of males and 4% of females in this sample were lifetime nitrite users. Although this difference was not statistically significant (p = .06), females were substantially overrepresented in the lifetime nitrite user group. Most (83%) nitrite users reported they had gotten high while using nitrites, but only one in six (17%) nitrite users had used nitrites on five or more days.

Modes and recency of use. The majority of nitrite users (58%) reported sniffing from a container such as a jar or bottle as their preferred mode of use. This modality may reference use of the small vials that are marketed and sold through the World Wide Web (Romanelli et al. 2004). Three users (25%) typically sprayed nitrites directly into their nose or mouth, and two (17%) users usually had sniffed or inhaled nitrites from a plastic bag placed over their nose, mouth, or head. Eleven of the 12 (92%) lifetime nitrite users reported nitrite use in the year prior to incarceration.

Differences between Lifetime Nitrite Users and Nonusers

Bivariate contrasts. Lifetime nitrite users and nonusers did not differ significantly with regard to grade level, age, urbanicity of family residence, or proportion reporting family receipt of public assistance. Significant differences across racial categories were observed for rates of lifetime nitrite use. Three-quarters (75%) of nitrite abusers identified as Caucasian; one identified as Latino (8%), and two nitrite abusers (17%) identified as "other" ethnicity.

Lifetime nitrite users did not differ significantly from nonusers with regard to the SRD total delinquency measure (M = 27.7, SD = 16.6 vs. M = 24.3, SD = 18.5). Though nitrite users' scores were considerably higher than nonusers' scores on the SRD property crime index (M = 19.3, SD = 10.3 vs. M = 13.9, SD = 11.9), this difference was not statistically significant. Likewise, nitrite users had higher mean scores on the victimization index (M = 8.8, SD = 7.9 vs. M = 6.3, SD = 5.9), and lower scores on the violent offending index (M = 8.3, SD = 9.2 vs. M = 10.4, SD = 9.5), but differences on these measures were not statistically significant.

Of the 12 nitrite users, 42% reported a history of head injury with loss of consciousness compared to 18% of nonusers [[chi square] (1) = 4.4, p = .05]. No nitrite users reported a history of other neurological problems, kidney disease, or hormonal disorders. Only one nitrite user reported suffering from a major illness or injury around the time of birth, and one nitrite user reported a blood disorder such as anemia or leukemia. Compared to nonusers, a higher percentage of nitrite users reported having received a diagnosis of mental illness (64% vs. 51%) and having "heard voices" (25% vs. 15%), though neither of these differences was statistically significant.

Nitrite users evidenced substantially more current psychiatric distress than non-nitrite users on the BSI Global Severity Index (M = 70.3, SD = 49.0 vs. M = 43.3; SD = 34.4, t [721] = 2.7, p = .08). Nitrite users had significantly higher scores than nonusers across all seven Somatization subscale items, six Obsessive-Compulsive subscale items, and four Interpersonal Sensitivity subscale items; Table 2 presents group means for the six scale items that reflect significant group differences. Nitrite users also scored significantly higher than nonusers on the PPI Carefree Nonplanfulness and Fearlessness subscales and MAYSI-2 measure of suicidality.

Nitrite users reported an average of 7.7 (SD = 3.6) different classes of psychoactive drugs used, compared to 3.9 (SD = 2.8) for nonusers [t (719) = 4.5, p < .001]. In addition, nitrite users were significantly more likely to have initiated use of 13 of the 20 drugs assessed, and had significantly greater frequency of lifetime use of opiates other than heroin, "speed," alcohol, and cigarettes. In no case were initiation rates or frequency of lifetime use rates higher in the non-nitrite-using group than in the group of lifetime nitrite users. Table 2 reports the drug use initiation rates and frequency of drug use group contrasts that were statistically significant.

Adjusted model. Logistic regression analysis was used to identify correlates of lifetime nitrite use while controlling for potentially confounding factors. Based on the results of these bivariate analyses, thirteen variables were included in the model. A correlation matrix was used to evaluate multicollinearity among the continuous variables. Missing data were noted for only 2% of the total sample.

An adjusted analysis with simultaneous entry of covariates was conducted using the following variables: gender, race ("White" vs. "non-White"), urbanicity of family residence, welfare, history of head injury, BSI-Somatization, BSI-Obsessive Compulsive, PPI-Carefree Nonplanfulness, PPI-Fearlessness, MAYSI-2-Suicide Ideation, and lifetime number of different drug types used. Model coefficients, statistical tests, odds ratios, and 95% confidence intervals for odds ratios are presented in Table 3. The simultaneous entry model was statistically significant [[chi square] (12) = 33.8, p < .05; -2 log likelihood = 87.8, p < .05]. No demographic factors were statistically significant when controlling for other variables. Of the remaining variables, only gender, lifetime number of drugs used and level of somatization symptoms were statistically significant predictors of nitrite use. The overall classification accuracy of the model was 98.4.

DISCUSSION

We found that 1.7% of a state population of antisocial youth had used nitrites, a figure slightly higher than the 1.2% reported for twelfth graders participating in the MTF Survey (Johnston et al. 2007) and the 1.5% lifetime prevalence rate reported for 12-to-17 year-olds participating in the 2000/2001 National Household Survey on Drug Abuse (NHSDA). Although the current study, MTF and NHSDA (now National Survey on Drug Use and Health) are limited by their reliance on respondent self-reports, the convergence of these findings provides some level of assurance that approximately 1% to 2% of adolescents have used nitrites illicitly.

Although absolute rates of lifetime use were low, the 1.7% prevalence estimate identified in this study is, proportionately speaking, 42% higher than the 1.2% figure observed in the MTF survey of high school seniors (a substantially older group of youth than that surveyed in this study). This finding is not unexpected, given the high-risk nature of the sample studied here. Most lifetime nitrite users had used nitrites recently and reportedly experienced intoxication in association with nitrite inhalation. However, even moderately intensive use of nitrites was uncommon among lifetime nitrite users and rare in the overall sample. Of course, given the youth of these respondents, it is possible that a number of study participants will commence, continue, or intensify nitrite use in the future.

Girls and White youth were disproportionately represented in the group of nitrite users. Wu and colleagues (2005) also found comparatively elevated rates of nitrite use in Caucasian and female adolescents. These findings are consistent with prior reports (e.g., Howard et al. 2008) indicating that females in residential treatment for antisocial behavior tend to exhibit more psychiatric symptomatology and substance use problems than their male counterparts. Nitrite users exhibited a high rate of serious head injury, significantly more current psychiatric distress in relation to somatizing, obsessive-compulsive and interpersonal sensitivity symptoms, were less temperamentally fearful or inclined to make and follow plans, reported higher levels of lifetime suicidality, and evidenced more varied and intensive drug use histories. Given the limited lifetime histories of nitrite use in the group of nitrite users, it is possible (if not highly probable) that the aforementioned characteristics antedated nitrite use and/or are attributable to a "third factor" that contributes both to enhanced risk for nitrite use and risk for other substance use, mental health, and some medical disorders.

Item-level analyses suggested that nitrite users reported symptoms possible reflective of cognitive problems including "difficulty making decisions" and distress in association, with your "mind going blank"; these effects may reflect the effects of head injury, high rates of use of neurotoxicants, or some combination thereof.

Although few studies have examined psychosocial correlates of nitrite use in adolescents, our findings accord well with those reported by Wu and colleagues (2005), who found number of lifetime psychoactive drug types used and other measures of antisociality to be the most potent predictors of lifetime nitrite use by U.S. adolescents.

It is notable that a number of statistically significant and clinically important differences were identified between nitrite users and nonusers in this sample. Although the overall sample was small in comparison to national survey efforts, the participation rate was high, and the structured interviews quite comprehensive. Nonetheless, relatively few nitrite users were identified and the antisocial nature of the sample may have restricted variability on a number of measures. A related concern for the multivariate logistic regression analysis was the relative sparsity of events per variable, which can lead to a failure to converge or produce biased estimates (Pedussi et al. 1996). Though the model described in this article converged, it is possible that coefficients were over- or underestimated. Thirty-four bivariate contrasts of lifetime nitrite users vs. nonusers were conducted; 26 of these contrasts were statistically significant--it is likely that between one and two of these 26 significant contrasts were spurious in nature.

Despite the aforementioned limitations, these findings replicate and extend those of prior reports and contribute usefully to the scant nitrite literature. This investigation is among the first to examine nitrite use in antisocial youth and to explore the associations of psychosocial factors to adolescent nitrite use. Future research should examine etiological factors disposing to nitrite use, assess medical and psychiatric consequences of acute and chronic nitrite use (using structured psychiatric and health assessments) and examine the natural history of nitrite use longitudinally. Nitrite abuse has been described in the substance abuse literature for more than 50 years, but remains among the most poorly understood of all forms of drug abuse.

With regard to policy and practice implications of the current findings, we believe studies are needed of the current availability of illicitly advertised nitrite products on the World Wide Web. Should such studies reveal ready availability of nitrite-containing products, enhanced regulatory and law enforcement measures are called for in an effort to reduce sales of nitrites over the Internet. At the practice level, it is important that routine screenings and assessments in a variety of clinical and service settings include at least one item assessing lifetime nitrite use. As the findings of the current article exemplify, nitrite inhalation can signify a host of clinically relevant comorbidities that could be addressed in treatment and rehabilitative settings. Few prevention initiatives have been designed with nitrite inhalants in mind. Groups at high risk for nitrite use should receive targeted prevention messages to reduce the likelihood of their nitrite use in the future.

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Martin T. Hall, Ph.D. * & Matthew O. Howard, Ph.D. **

[dagger] This study was supported by grants DA021405 (Natural History, Comorbid Mental Disorders, and Consequences of Inhalant Abuse, M.O. Howard, PI), and DA15929 (Neuropsychiatric Impairment in Adolescent Inhalant Abusers, M.O. Howard, PI) from the National Institute on Drug Abuse. The National Institute on Drug Abuse had no role in the design or conduct of the study; collection, management, analysis, and interpretation of the data; or preparation, review, or approval of the manuscript.

* National Institute on Drug Abuse Post-Doctoral Fellow, University of Kentucky, Department of Behavioral Science, Lexington, KY.

** Frank A. Daniels, Jr., Distinguished Professor, University of North Carolina at Chapel Hill, Chapel Hill, NC.

Please address correspondence and reprint requests to Matthew O. Howard, Ph.D., Frank A. Daniels, Jr., Distinguished Professor, University of North Carolina, Campus Box 3550, Chapel Hill, NC 27599; Phone: (919) 932-8732 or (314) 330-3479; email: mohoward@email.unc.edu
TABLE 1
Demographic and Health Characteristics of 723 Adolescents
Incarcerated in 27 Missouri Division of Youth Services'
Residential Facilities *

Demographics N (%)
Age

 11-12 9 (1.2)
 13-14 120 (16.6)
 15-16 472 (65.3)
 17-18 114 (15.8)
 19-20 8 (1.1)
Gender
 Male 629 (87.0)
 Female 94 (13.0)
Urbanicity of Residence
 Urban 283 (39.1)
 Suburban 100 (13.8)
 Small Town 286 (39.6)
 Rural 54 (7.5)
Race
 African American 238 (33.0)
 Caucasian 400 (55.4)
 Latin?/Latina 28 (3.9)
 Bi/Multi-Racial 56 (7.7)
Current/Last Grade
 Fifth-Sixth 19 (2.6)
 Seventh-Eighth 149 (20.7)
 Ninth-Tenth 444 (61.6)
 Fleventh-Twelfth 109 (15.1)

Medical History **
Head Injury with Period of Unconsciousness

 Yes 132 (18.3)
 No 588 (81.7)

Mental Illness Diagnosed by Psychiatrist
or Other Physician

Yes 370 (51.4)
No 350 (48.6)

Major Perinatal Injury or Illness
Yes 49 (6.8)
No 671 (93.2)

* There were three missing values for the history of head injury,
mental illness, and perinatal illness or injury variables, and two
missing values for the grade, one for race, and one for history of
hormonal disorder measures.

** Disorder with prevalence rates of 4% or less included neurological
(2.1 %), kidney (0.8%), hormonal (1.1 %?) and blood disorder (3.2%).

TABLE 2

Bivariate Contrasts of Lifetime Nitrite Users (N =12) and Nonusers
(N = 710) Across Criminological, Health, Mental Health, Attitudinal,
and Substance Use Measures

Variables Lifetime Nitrite Users

Demographic N (%)
Gender
 Male 8 (66.7%)
 Female 4 (33.3%)
Race ***
 African-American 0 (0.0%)
 White 9 (75.0%)
 Latino 1 (8.3%)
 Biracial 0 (0.0%)
 Other 2 (16.7%)
Ph?sical and Mental Health N (%)
 History of Head Injury 5 (41.7%)
Brief Symptom Inventory M (SD)
 Global SeveritY Index 70.3 (49.0)
 Somatization 8.5 (6.2)
 Faintness or Dizziness 0.9 (1.0)
 Nausea or Upset Stomach 1.5 (1.0)
 Hot or Cold Spells 1.4 (1.5)
 Obsessive-Compulsive 10.4 (6.7)
 Difficult? Making Decisions 1.9 (1.6)
 Mind Going Blank 1.8 (1.5)
 Interpersonal Sensitivity 5.2 (5)
 Feelings Easily Hurt 1.3 (1.2)
Psychopathic Personality Inventory M (SD)
 Carefree Nonplanfulness 16.5 (5.3)
 Fearlessness 20.8 (3.9)
Massachusetts Youth Screening Inventory
M (SD)
 MAYSI-Suicide Ideation 4.1 (2.2)
Substance Use and Related Problems
 Lifetime # of Drug Types Used, M (SD) 7.7 (3.6)
 Lifetime Heroin Use *, N (%) 6 (50.0%)
 Other Opiates Use, N (%) 8 (66.7%)
 Da?s of Opiate Use **, M (SD) 3.3 (1.2)
 Lifetime Cocaine Use, N (%) 8 (66.7%)
 Lifetime Barbiturates Use, N (%) 8 (66.7%)
 Lifetime Tranquilizers Use, N (%) 9 (75.0%)
 Lifetime Speed Use, N (%) 8 (66.7%)
 Da?s of Speed Use, M (SD) 3.6 (0.5)
 Lifetime LSD Use, N (%) 8 (66.7%)
 Lifetime Ecstasy Use, N (%) 7 (58.3%)
 Lifetime GHB Use, N (%) 2 (16.7%)
 Lifetime Ketamine Use, N (%) 4 (33.3%)
 Lifetime Cough Syrup Use, N (%) 5 (41.7 %)
 Lifetime PCP Use, N (%) 6 (50.0%)
 Days of Marijuana, M (SD) 3.8 (0.5)
 Days of Alcohol Use, M (SD) 3.5 (0.7)
 Days of Cigarette Use, M (SD) 3.9 (0.3)

Variables Nonusers

Demographic N (%)
Gender
 Male 621 (87.3%)
 Female 90 (12.7%)
Race ***
 African-American 238 (33.5%)
 White 391 (55.1 %)
 Latino 27 (3.8%)
 Biracial 45 (6.3%)
 Other 9 (1.3%)
Ph?sical and Mental Health N (%)
 History of Head Injury 127 (17.9%)
Brief Symptom Inventory M (SD)
 Global Severity Index 43.3 (34.4)
 Somatization 3.5 (4.2)
 Faintness or Dizziness 0.3 (0.8)
 Nausea or Upset Stomach 0.6 (1.0)
 Hot or Cold Spells 0.4 (0.9)
 Obsessive-Compulsive 6.5 (5.3)
 Difficulty Making Decisions 1.1 (1.2)
 Mind Going Blank 0.8 (1.2)
 Interpersonal Sensitivity 2.8 (3.3)
 Feelings Easily Hurt 0.6 (1)
Psychopathic Personality Inventory M (SD)
 Carefree Nonplanfulness 14.1 (3.9)
 Fearlessness 17.0 (5.3)
Massachusetts Youth Screening Inventory
M (SD)
 MAYSI-Suicide Ideation 2.2 (2.4)
Substance Use and Related Problems
 Lifetime # of Drug Types Used, M (SD) 3.9 (2.8)
 Lifetime Heroin Use *, N (%) 41 (5.8%)
 Other Opiates Use, N (%) 225 (31.6%)
 Da?s of Opiate Use **, M (SD) 2.2 (1.2)
 Lifetime Cocaine Use, N (%) 161 (22.6%)
 Lifetime Barbiturates Use, N (%) 72 (10.1%)
 Lifetime Tranquilizers Use, N (%) 220 (30.9%)
 Lifetime Speed Use, N (%) 225 (31.7%)
 Da?s of Speed Use, M (SD) 2.6 (1.2)
 Lifetime LSD Use, N (%) 159 (22.4%)
 Lifetime Ecstasy Use, N (%) 136 (19.1%)
 Lifetime GHB Use, N (%) 11 (1.5%)
 Lifetime Ketamine Use, N (%) 22 (3.1%)
 Lifetime Cough Syrup Use, N (%) 119 (16.7%)
 Lifetime PCP Use, N (%) 148 (20.8%)
 Days of Marijuana, M (SD) 3.4 (1.0)
 Days of Alcohol Use, M (SD) 2.8 (1.1)
 Days of Cigarette Use, M (SD) 3.6 (0.9)

Variables Results

Demographic N (%)
Gender
 Male [chi square] (1) = 4.4
 Female p = .06
Race ***
 African-American [chi square] (4) = 15.8
 White p < .01
 Latino
 Biracial
 Other
Ph?sical and Mental Health N (%)
 History of Head Injury [chi square] (1) = 4.4,
 p = .05
Brief Symptom Inventory M (SD)
 Global Severity Index t (721) = 2.7, p = .08
 Somatization t (721) = 2.7, p < .05,
 d = .20
 Faintness or Dizziness t (721) = 2.6, p < .05
 Nausea or Upset Stomach t (721) = 3.1, p < .01
 Hot or Cold Spells t (11.1) = 2.3, p < .05
 Obsessive-Compulsive t (721) = 2.5, p < .05,
 d = .18
 Difficulty Making Decisions t (721) = 2.2, p < .05
 Mind Going B1ank t (721) = 2.8, p < .01
 Interpersonal Sensitivity t (721) = 2.4, p < .05,
 d = .18
 Feelings Easily Hurt t (719) = 2.1, p < .05
Psychopathic Personality Inventory M (SD)
 Carefree Nonplanfulness t (721) = 2.0, p < .05,
 d = .15
 Fearlessness t (721) = 2.5, p < .05,
 d = .19
Massachusetts ???th Screening Inventory
M (SD)
 MAYSI-Suicide Ideation t (720) = 2.8, p < .01,
 d= .21
Substance Use and Related Problems
 Lifetime # of Drug Types Used, M (SD) t (719) = 4.5, p < .001
 Lifetime Heroin Use *, N (%) [chi square] (1) = 38.0,
 p < .001
 Other Opiates Use, N (%) [chi square] (1) = 6.6,
 p < .05
 Da?s of Opiate Use **, M (SD) t (231) = 2.4, p < .05
 Lifetime Cocaine Use, N (%) [chi square] (1) = 12.8,
 p < .01
 Lifetime Barbiturates Use, N (%) [chi square] (1) = 38.3,
 p < .001
 Lifetime Tranquilizers Use, N (%) [chi square] (1) = 10.6,
 p < .01
 Lifetime Speed Use, N (%) [chi square] (1) = 6.6,
 p < .05
 Days of Speed Use, M (SD) t (9.85) = 5.1, p < .001
 Lifetime LSD Use, N (%) [chi square] (1) = 13.0,
 p < .01
 Lifetime Ecstasy Use, N (%) [chi square] (1) = 11.4,
 p < .01
 Lifetime GHB Use, N (%) [chi square] (1) = 15.3,
 p < .05
 Lifetime Ketamine Use, N (%) [chi square] (1) = 31.1,
 p< .01
 Lifetime Cough Syrup Use, N (%) [chi square] (1) = 5.2,
 p < .05
 Lifetime PCP Use, N (%) [chi square] (1) = 6.0,
 p < .05
 Days of Marijuana, M (SD) t (12.2) = 2.2, p < .05
 Days of Alcohol Use, M (SD) t (611) = 2.1, p < .05
 Days of Cigarette Use, M (SD) t (13.5) = 3.6, p < .01

* Lifetime drug ?se variables describe the proportion of each group
that reported ever using a particular agent or class of agents.
Due to space limitations, nonsignificant substance use group
comparisons were not reported.

** The response forn?at for the lifetime frequenc? of drug use
variables was: 1 = < 5, 2 = 5 to 10, 3 = 11 to 99, 4 = [greater than
or equal to] 100 1ifetime da?s of use of that agent or class of
agents).

*** Racial status was missing one value.

TABLE 3
Multiple Logistic Regression Analysis Examining Correlates of
Lifetime Nitrite Use in Total Sample of Nitrite Users (N =12)
and Nonusers (N = 695)

Variable b SE Wald p

Sex:
 Male * --
 Female 1.5 .76 3.80 .05
Race:
 Non-White * --
 White .30 .78 .15 .70
Welfare -1.5 .85 3.00 .08
Lifetime # of Drugs Used .32 .11 7.70 <.01
Urbanicity of Family Residence:
 Small Town/Rural *
 Urban/Suburban -.52 .69 .56 .46
BSI-Somatization .18 .08 5.10 .02
BSI-Obsessive Compulsive -.11 .09 1.50 .22
BSI-Interpersonal Sensitivity -.03 .11 .07 .80
PPI-Fearlessness .09 .08 1.30 .26
PPI-Carefree Non-planfulness .02 .08 .09 .77
History of Head Injury .69 .72 .94 .33
Suicidal Ideation .07 .16 .18 .67
Constant -9.7 2.3 17.1 .00

 Odds 95.0% CI (OR)
Variable Ratio Lower Upper

Sex:
 Male *
 Female 4.4 .99 19.1
Race:
 Non-White *
 White 1.3 .30 6.2
Welfare .23 .04 1.2
Lifetime # of Drugs Used 1.4 1.1 1.7
Urbanicity of Family Residence:
 Small Town/Rural *
 Urban/Suburban .60 .15 2.3
BSI-Somatization 1.2 1.0 1.4
BSI-Obsessive Compulsive .90 .75 1.1
BSI-Interpersonal Sensitivity .97 .78 1.2
PPI-Fearlessness 1.1 .94 1.3
PPI-Carefree Non-planfulness 1.0 .87 1.2
History of Head Injury 2.0 .49 8.2
Suicidal Ideation 1.0 .79 1.5
Constant .00
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Author:Hall, Martin T.; Howard, Matthew O.
Publication:Journal of Psychoactive Drugs
Article Type:Report
Geographic Code:1USA
Date:Jun 1, 2009
Words:7308
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