7
Consequences

The ramifications of drug abuse extend far beyond the individual drug abuser, because the health and social consequences of drug abuse HIV/AIDS (human immunodeficiency virus/acquired immune deficiency syndrome), violence, tuberculosis, fetal effects, crime, and disruptions in family, workplace, and educational environments (Box 7.1)-have devastating impacts on society and exact a cost of billions of dollars annually.1 Drug abuse is often the result of a constellation of factors including socioeconomic status, educational achievement, co-occurring psychiatric disorders, access to health care, employment status, and numerous other factors present in the lives of drug-abusing individuals (see Chapter 5). Regardless of the factors at work, it is the ultimate goal of the nation's investment in drug abuse research to take more effective measures to prevent drug abuse and to reduce its associated costs and consequences.

A comprehensive assessment of knowledge and research opportunities on the multiple consequences of drug abuse would have far exceeded the committee's allowable time frame and expertise. Consequently, it chose to focus on three areas that involve pronounced social consequences, where the need for strategic interventions are greatest: (1) the transmission and course of HIV infection; (2) fetal and child development; and (3) violent behavior.

1  

It should be noted that negative consequences can derive from patterns of problematic use that do not meet the criteria for abuse and dependence as well as from abuse or dependence.



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Pathways of Addiction: Opportunities in Drug Abuse Research 7 Consequences The ramifications of drug abuse extend far beyond the individual drug abuser, because the health and social consequences of drug abuse HIV/AIDS (human immunodeficiency virus/acquired immune deficiency syndrome), violence, tuberculosis, fetal effects, crime, and disruptions in family, workplace, and educational environments (Box 7.1)-have devastating impacts on society and exact a cost of billions of dollars annually.1 Drug abuse is often the result of a constellation of factors including socioeconomic status, educational achievement, co-occurring psychiatric disorders, access to health care, employment status, and numerous other factors present in the lives of drug-abusing individuals (see Chapter 5). Regardless of the factors at work, it is the ultimate goal of the nation's investment in drug abuse research to take more effective measures to prevent drug abuse and to reduce its associated costs and consequences. A comprehensive assessment of knowledge and research opportunities on the multiple consequences of drug abuse would have far exceeded the committee's allowable time frame and expertise. Consequently, it chose to focus on three areas that involve pronounced social consequences, where the need for strategic interventions are greatest: (1) the transmission and course of HIV infection; (2) fetal and child development; and (3) violent behavior. 1   It should be noted that negative consequences can derive from patterns of problematic use that do not meet the criteria for abuse and dependence as well as from abuse or dependence.

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Pathways of Addiction: Opportunities in Drug Abuse Research BOX 7.1 Consequences of Drug Abuse HIV/AIDS It now appears that injection drug use is the leading risk factor for new human immunodeficiency virus (HIV) infections in the U.S. (Holmberg, 1996). Drug and alcohol abuse heightens the risk for unsafe sexual behavior and is a factor in perinatal transmission of HIV. TB Tuberculosis (TB) rates have increased significantly among drug-using populations, especially drug-resistant TB in HIV-infected drug users. Other diseases and illnesses Injection drug users (IDUs) are more likely to develop serious infections and illnesses (e.g., viral hepatitis, endocarditis, pneumonia, other bacterial infections) than the non-IDU population due to the harmful effects of drug injection and their infrequent use of primary medical care services. Additionally, some forms of psychiatric disorders may result in part from drug abuse (e.g., depression, PCP-precipitated psychosis). Fetal and child development Drug abuse can impact the health of the developing fetus and child. Consequences include retardation of fetal growth, fetal alcohol syndrome, neonatal withdrawal syndrome, and neonatal neurobehavioral affects. Violence and crime Violence and crime are linked to illicit drug abuse through the often violent nature of drug sales and distribution. Additionally, some drug addicts resort to theft to support their drug habits. Pharmacological effects of drug abuse associated with violent actions may occur de novo or with predating co-occurring psychiatric disorders. Violence and crime are linked to illicit drug abuse through the often violent nature of drug sales and distribution. Additionally, some drug addicts resort to theft to support their drug habits. Pharmacological effects of drug abuse associated with violent actions may occur de novo or with predating co-occurring psychiatric disorders. Public safety Drug abuse plays a role in numerous transportation or other accidents. For example, the National Highway Traffic Safety Administration estimates that 40.8 percent of traffic fatalities were alcohol related (NHTSA, 1995). Loss of human capital Drug abuse can have devastating impacts on an individual's potential (e.g., school delinquency, dropping out of school, involvement in illicit drug selling), thus reducing future educational and job opportunities. Workplace Employee drug use, particularly heavy use or abuse, has been found to be associated with increased absenteeism, accidents, job turnover, counterproductive behavior, and job dissatisfaction (NRC, 1994). However, drug abuse does not occur in isolation, and other related life-style behaviors are strongly correlated with employment difficulties.

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Pathways of Addiction: Opportunities in Drug Abuse Research Family Drug abuse leads to reallocation of economic support away from the family; lack of participation in family activities, including caregiving; lack of emotional commitment and support for parents and children; and the inability to provide a reliable and adequate role model for other family members, especially children. This impact on the family affects children's development, leaming, and social relations whether or not actual child abuse and neglect occur. Education Drug-abusing students may develop cognitive and behavioral difficulties; disrupt classes; have increased psychosocial problems; or be delinquent in attending school or drop out of school (Kandel and Davies, 1996). Additionally, violence increases as buying and selling of drugs occurs at the school site. HIV/AIDS Today more than 17 million people worldwide, including an estimated 1 million Americans, are infected with the human immunodeficiency virus (HIV) which causes AIDS. In the United States, according to the Centers for Disease Control and Prevention (CDC), AIDS is now the leading cause of death among 25- to 44-year-olds (Swan, 1995). It now appears that injection drug use is the leading risk factor for new HIV infection in the United States (Holmberg, 1996). More than onethird of AIDS cases reported through December 1995 were related to injection of illicit drugs through three mechanisms: the sharing of contaminated injection equipment, heterosexual contact with an injection drug user (IDU), or through maternal injection of illicit drugs (Table 7.1) (CDC, 1995a). In women, the percentages of AIDS cases involving injection of illicit drugs are alarmingly high. Of the 71,818 female AIDS cases reported to CDC through December 1995, almost half (33,452 cases) were related to injection of illicit drugs and another 18 percent (13,046 cases) to sex with infected IDU partners (CDC, 1995a). HIV can be transmitted through direct needle sharing when contaminated blood remains in the syringe and may be released into the next user or through certain injection drug practices during which blood is drawn into the syringe and mixed with the drug. Transmission of the virus can also occur indirectly by the sharing of drug injection equipment such as cotton balls or rinse water (NRC, 1995), and increased frequency of injection and the use of shared equipment increase the risk for seropositivity. HIV risk is also associated with the locations in which drug use occurs.

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Pathways of Addiction: Opportunities in Drug Abuse Research TABLE 7.1 AIDS Cases Related to Injection of Illicit Drugs (percentage of total cases) Exposure Category Cases Reported in 1995 Cumulative Total Reported Through December 1995 Injection drug use         Men 14,057 (19) 95,244 (18.5) Women 5,204 (7) 33,452 (6.5) Heterosexual contact with an injection drug user         Men 928 (1.2) 5,664 (1.1) Women 1,921 (2.6) 13,046 (2.5) Men who have sex with men and inject drugs 3,425 (4.6) 33,195 (6.5) Pediatric cases (<13 years old)         Mother who is an injection drug user 211 (0.3) 2,594 (0.5) Mother who has sex with an injection drug user 114 (0.2) 1,164 (0.2) Total cases related to injection drug use 25,860 (34.9) 184,359 (35.8) Total cases reported 74,180 (100) 513,486     SOURCE: CDC (1995a). Injection drug use frequently occurs in ''shooting galleries" where users can rent a syringe and needle that is supplied from a common container. The injection equipment may or may not be rinsed, and if rinsed, may be rinsed with infected water.2 All drug users, injecting and noninjecting, place themselves at great risk for HIV transmission when engaging in unsafe sexual behavior while under the influence of drugs, such as alcohol and cocaine, or exchanging sex for money or drugs (Edlin et al., 1994; O'Connor et al., 1994). One study found that as many as 80 percent of male IDUs were in a primary 2   Studies have shown that HIV can survive in tap water for extended periods of time (Resnick et al., 1986).

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Pathways of Addiction: Opportunities in Drug Abuse Research relationship with women who did not use drugs themselves (Des Jarlais et al., 1984). Since the beginning of the crack cocaine epidemic, that drug has been seen as a sexual stimulant, as well as the cause of high-risk sexual behavior in many users. The disinhibiting effect is stronger than that of depressants such as alcohol or heroin due to the rapid onset of the drug's "high" with a related rapid release of inhibitions (Fullilove and Fullilove, 1989; Chaisson et al., 1991; Edlin et al., 1994). Sex-for-drug exchanges and prostitution—associated with the need to acquire crack cocaine or the money to buy the drug—have resulted in the transmission of HIV to the non-drug-using populations (IOM, 1994). Maternal-infant transmission of HIV is often an indirect health consequence of injection drug use. Of the 6,948 cases of AIDS in children under 13 years of age reported to CDC through December 1995, 90 percent are attributable to perinatal HIV transmission. Most (54 percent) of the pediatric AIDS cases are associated with injection of illicit drugs—37 percent with maternal injection of drugs and 17 percent with maternal sexual contact with an IDU (CDC, 1995a). Of all infants born to HIV-infected mothers who do not receive antiretroviral therapy (e.g., AZT), an estimated 15-35 percent of those infants become infected (Hardy, 1991; CDC, 1994, 1995b). As the AIDS epidemic continues to spread, the financial burden of the disease on those affected, the health care system, and society in general will continue to grow. Because data on the use of and expenditures for medical services of persons with AIDS are scarce, the Agency for Health Care Policy and Research (AHCPR) established the AIDS Cost and Service Utilization Survey (ACSUS) in 1989. Estimates in 1992 forecast that the cumulative (national) costs of treating all HIV-infected individuals would surpass $15.2 billion in 1995 (see Table 7.2). That figure, which represents a 48 percent increase from the cost of $10.3 billion in 1992, reflects an increase in the average amount of services used by those infected with HIV as well as the availability of better data on the utilization of medical services (Hellinger, 1992; Oncology, 1993). TABLE 7.2 Estimated Costs of AIDS Costs 1991 1992 1995 Cost of treating all HIV-infected persons in the United States $2.3 billion $10.3 billion $15.2 billion   SOURCES: Adapted from Scitovsky and Rice (1987), Hellinger (1992), Oncology (1993).

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Pathways of Addiction: Opportunities in Drug Abuse Research Research Opportunities The United States funds 85 percent of the world's public sector investment in AIDS research, primarily through the National Institutes of Health (NIH) whose AIDS and AIDS-related research portfolio is currently a $1.4 billion effort (OAR, 1996). Research is aimed at all phases of the etiology, prevention, and treatment of the disease. The research accomplishments to date are numerous. This section highlights future research directions related to IDUs and AIDS research. Chapter 8 discusses further research opportunities in the treatment of HIV-infected drug abusers. HIV Epidemiology Measuring HIV prevalence (the number of infections at a point in time) and incidence (the number of new infections over time) is crucial to monitoring the course of the epidemic. Statistics on the incidence and prevalence of HIV infection provide a more complete assessment of the magnitude of the epidemic than end-stage statistics of AIDS cases. Efforts to determine HIV prevalence in the drug-abusing population have been based on a range of seroprevalence studies primarily of IDUs. The number of IDUs in the United States has been estimated to range from 1.1 million to 1.8 million (NRC, 1989; OTA, 1990). Estimates of HIV seroprevalence in the IDU population range from 0 to 50 percent depending largely on geographic location. In New York City, HIV seroprevalence was found to be slightly more than 50 percent in a study of injection drug users (Des Jarlais et al., 1994). The Centers for Disease Control and Prevention's HIV/AIDS Surveillance Report provides data on new HIV cases in IDUs. However, these data are not representative of all persons with HIV infection because some states also offer anonymous HIV testing, and the collection of demographic and risk information varies greatly among states (CDC, 1995a). Because of the difficulties in locating and gaining access to the populations initiating or relapsing into injecting drugs, most of the epidemiological studies to date have focused on long-term, chronic IDUs (IOM, 1994). As a result, little is known about younger, new IDUs who may actually be at increased risk for HIV transmission due to engaging in higher levels of risk behaviors, including needle sharing and use of shooting galleries (Battjes et al., 1992). Additionally, little is known about the extent of HIV transmission that is due to sex-for-drug activities or drug-related prostitution. Studies are needed to determine the prevalence of HIV infection among vulnerable populations of drug users. Information from such stud-

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Pathways of Addiction: Opportunities in Drug Abuse Research ies may help establish a basis for possible intervention programs directed at preventing further HIV transmission. More extensive epidemiological data regarding HIV incidence in the drug-using population are needed in order for AIDS treatment programs to accurately and adequately meet the needs of those infected. Prevention and Risk Reduction Strategies AIDS prevention intervention research is focused mainly on identifying and modifying behaviors known to be associated with HIV transmission; it targets individuals at high risk because of drug use and sexual contact. Education on hygienic injection practices and HIV transmission routes, condom distribution programs, and enrollment in drug abuse treatment are currently the major risk reduction interventions aimed at drug users in the United States. Additionally, there are other programs to prevent HIV infection that have incorporated social interventions to effect change in risky behaviors (Friedman et al., 1992). Drug abuse treatment has demonstrated varying degrees of success in the reduction of risk factors for HIV among populations of IDUs, primarily through prevention education (Watkins et al., 1992). Studies have shown that drug abuse treatment is associated with reductions in HIV risk behaviors, including reductions in drug use, in risky injection practices, and in the number of sex partners (Ball et al., 1988; Watkins et al., 1992; Longshore et al., 1994; Serpelloni et al., 1994). In general, it has proven to be more difficult to change sexual risk behaviors than to change drug injection behaviors (Des Jarlais, 1992; Battjes et al., 1995). Recent evidence has shown a decrease in the use of contaminated drug paraphernalia when needle exchange is available (Des Jarlais et al., 1994). For example, the use of contaminated needles declined from 51 percent of injections in 1984 to 7 percent in 1992 in a study of New York City IDUs (Des Jarlais et al., 1994). That work confirms other studies that found HIV risk reduction behaviors among IDUs (Vlahov et al., 1991; Schottenfeld et al., 1993). As noted in a recent National Research Council (NRC, 1995) report, research has also shown that needle exchange programs do not affect the level of drug use among participants and do not appear to recruit new users to injection drugs. Additionally, needle exchange programs can also provide strategic and important sites for the deployment of primary care services and referral for persons with or at risk of HIV infection. Whereas needle exchange programs have been adopted in some European countries and have been associated with a reduction in the incidence of HIV infection (Hart et al., 1989; Hartgers et al., 1989; Ljungberg et al., 1991) and no increase in illicit drug use, such

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Pathways of Addiction: Opportunities in Drug Abuse Research programs have been resisted in the United States.3 Continued research is needed on the impact of needle exchange programs and on ways to improve their effectiveness along the lines recommended in the NRC report (see also Chapter 10). Although risk reduction strategies have primarily targeted current injection drug users, it is important for research to focus also on preventing initiation into intravenous drug use. A study by Battjes and colleagues (1992) found that early age of first injection is associated with higher levels of injection and sexual risk behaviors (including needle sharing, frequency of injection, use of shooting galleries, multiple sex partners, and prostitution). The committee recommends continued and expanded research efforts regarding noninjecting and injecting drug use and HIV transmission. Specifically, epidemiological studies of the prevalence and correlates of HIV infection in vulnerable populations of drug users and IDUs; and studies of effective risk reduction strategies for changing sexual risk behaviors and drug injection behaviors are needed. IMPACTS ON FETAL, INFANT, AND CHILD DEVELOPMENT Drug abuse can have a significant impact on the health of children who either are exposed to nicotine, alcohol, or illicit drugs prenatally through maternal drug abuse or grow up in a drug-abusing household. Although it is difficult to estimate the number of children in drug-abusing households, the National Pregnancy and Health Survey, sponsored by the National Institute of Drug Abuse (NIDA), provides nationwide estimates of the use of nicotine, alcohol, and illicit drugs by pregnant women. The survey estimated that in 1992, 20.4 percent of the women (an estimated 820,000 women) smoked cigarettes and 18.8 percent (757,000) used alcohol during pregnancy (NIDA, 1996). The survey also found that 5.5 percent of the women who gave birth (approximately 221,000 women out of 4 million nationally) used one or more illicit drugs during pregnancy; an estimated 119,000 women (2.9 percent) used marijuana, 45,000 (1.1 percent) used cocaine (34,800 of whom used crack cocaine), and 3,600 used heroin during pregnancy (NIDA, 1996).4 3   However, a recent survey reported 76 needle exchange programs in 55 U.S. cities (NRC, 1995). 4   Correlations performed on survey results found that drug use varied by the number of prenatal care visits (mothers with fewer than five prenatal care visits had the highest rates

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Pathways of Addiction: Opportunities in Drug Abuse Research The economic costs of maternal drug use during pregnancy were estimated to exceed $500 million in 1990 for cocaine-exposed infants and $652 million annually for maternal cigarette smoking (Manning et al., 1989a,b; Phibbs et al., 1991; Frank et al., 1993). Prenatal exposure to these drugs may result in prematurity and low birth weight, which is one of the primary causes of extended hospital stays for drug-exposed infants. For example, a premature cocaine-exposed infant's hospital stay costs an average of $5,200 more than the cost of an unexposed infant (Phibbs et al., 1991). It is more difficult to estimate the cost of other health effects due to prenatal exposure (e.g., HIV infection5) or the collateral effects (e.g., homelessness, child abuse, neglect, and malnutrition) of growing up in a drug-abusing household. The next section provides an overview of the known effects of nicotine, alcohol, heroin, marijuana, and cocaine on fetal development and on later behavior and developmental outcomes. It is followed by a discussion of opportunities for future research on prenatal exposure and on the effects of growing up in a drug-abusing household. Discussion is limited to nicotine, alcohol, heroin, marijuana, and cocaine because those drugs appear to be the most widely used during pregnancy, with the possible exception of caffeine. Before describing the accomplishments, however, the methodological difficulties associated with conducting research on prenatal exposure are discussed. Methodological Issues Nicotine, alcohol, heroin, marijuana, and cocaine readily cross the placenta and the blood-brain barrier, creating a potentially increased risk of adverse biological consequences to overall fetal development and specifically to fetal brain development. In most instances, however, demonstrating links between prenatal exposure and immediate or later outcomes is complicated by issues such as interactions with associated conditions     of illicit drug use), income level (women with a household income level greater than $50,000 had lower rates of illicit drug or cigarette use but the highest rates of alcohol use), and hospital size (hospitals with 3,000 or more births annually and urban metropolitan hospitals had the highest rates of illicit drug use) (NIDA, 1996). 5   Vertical transmission of HIV from mother to child may be a consequence of maternal injection drug use or maternal sexual contact with an HIV-infected person. As discussed in the previous section on AIDS, of the 6,948 cases of AIDS in children under 13 years of age reported to CDC through December 1995, 90 percent are attributable to perinatal HIV transmission and 54 percent of those cases are associated with injection of illicit drugs (CDC, 1995a). Additionally, maternal drug abuse is a risk factor for congenital syphilis and transmission of hepatitis (Weintrub et al., 1991; Frank et al., 1993; Webber et al., 1993).

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Pathways of Addiction: Opportunities in Drug Abuse Research (e.g., poor nutrition, parental stress and psychiatric illness, sexually transmitted diseases) that may also impact on development (Frank et al., 1993; Finnegan, 1994). Further, the majority of women who use heroin, marijuana, or crack cocaine also use varying amounts of alcohol and/or nicotine and may use one or more illicit drugs in combination. Thus, rarely is it possible to speak, for example, of a "pure" crack cocaine effect. Additionally, longitudinal studies of the developmental outcome of prenatal drug exposure in human infants face four methodological issues that cut across the specific agent of abuse and exposure (reviews by Jacobson and Jacobson, 1995; Neuspiel, 1995; Olson et al., 1995). First, there are difficulties in ascertaining the amount, frequency, and duration of drug abuse during pregnancy due to inaccuracies of maternal selfreport and limitations of current biological markers of exposure (Coles, 1992; Kidwell, 1992). Second, the high rate of attrition is a problem in studies of drug-abusing populations (Mayes and Cicchetti, 1995). Third, there are difficulties in choosing the appropriate comparison group (e.g., determining whether the comparison group is drug free or free only of the primary drug of interest, choosing appropriate demographic comparison cohorts). Fourth, determining the appropriate time (developmentally) and length of time to assess infants is another crucial issue. Traditional models of behavioral teratology presume effects that are present at least early in infancy but may or may not persist through childhood. Less frequently discussed are drug-related effects that are not apparent until later in development, when central nervous system processing of information or social skills are required, or during periods of major central nervous system reorganization (e.g, between age 4 and 5 years or during puberty) (see Weiss, 1995). Animal models provide some basis for comparison because the amount of exposure and environmental conditions may be controlled. Animal models have been particularly useful for studies of the effects of prenatal exposures and for modeling drug-related effects on brain development at the structural, cellular, and functional levels. Neurobehavioral data from animal models should be viewed carefully, however, when extrapolating results from animal models to the complex developmental capacities found in higher primates and humans (e.g., language, complex problem-solving tasks, and neuropsychological functions such as certain domains of memory) (see Stanton and Spear, 1990). Accomplishments Prenatal Nicotine Exposure Nicotine acts as a vasoconstrictor, reducing placental blood flow and

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Pathways of Addiction: Opportunities in Drug Abuse Research the amount of oxygen and nutrients available to the fetus through several mechanisms. Additionally, smoking reduces the mother's appetite, and carbon monoxide from cigarette smoke crosses the placenta, increasing fetal carboxyhemoglobin levels (Werler et al., 1985). Those mechanisms are associated with retarding intrauterine growth in an apparent doseresponse relationship; the more cigarettes smoked, the lower is the birth weight (Zuckerman, 1991).6 Maternal cigarette smoking is also linked to higher rates of negative outcomes, including spontaneous abortions (Risch et al., 1988), stillbirths and perinatal death (Cnattingius et al., 1988; Malloy et al., 1988), and sudden infant death syndrome (SIDS) (Werler et al., 1985; Kandall and Gaines, 1991; Fried, 1992). Additionally, other toxins in cigarettes, including cadmium, lead, and thiocyanate, may also have adverse effects on the developing fetus (Kuhnert, 1991). Nicotine may affect fetal brain development both indirectly (through nicotine-associated hypoxia) and directly (through specific nicotinic receptors) (Slotkin, 1992). In animal models, it appears that there is a lower dose threshold for adverse effects of fetal nicotine exposure on neuronal development than on overall growth (Slotkin, 1992). The literature regarding later neuro-behavioral outcomes in nicotine-exposed infants and children is not as extensive or as conclusive as those studies regarding pregnancy and birth outcomes (Fried, 1992). One study has found that maternal smoking during pregnancy, when postnatal smoking was controlled, selectively increased the probability that female children would smoke as adolescents and would continue to smoke (Kandel et al., 1994). There is suggestive evidence of a relationship between maternal smoking and later adverse developmental outcomes, including effects on attention and auditory responsiveness (Fried and Watkinson, 1988, 1990). However, those effects, if any, have a small attributable risk. Prenatal Alcohol Exposure Alcohol in high doses is a potentially potent teratogen associated with a range of consequences, including congenital anomalies and neurodevelopmental impairments (reviewed in IOM, 1995). In high doses, alcohol acts as a direct neuroteratogen, affecting all aspects of fetal growth (including brain growth, structure, and function) through mechanisms 6   Intrauterine growth retardation (IUGR) can be caused by a number of factors including undernutrition and is associated postnatally with impaired neuromotor performance, including decreased motor maturity, poor state control, and abnormal reflexes (Tronick and Beeghly, 1992). Studies have reported long-term consequences of IUGR, including language delay and poor academic performance, but a direct cause-effect relationship for long-term effects is still considered inconclusive.

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Pathways of Addiction: Opportunities in Drug Abuse Research drug abuse and depression (Monahan, 1995). Of those with bipolar disorder (without drug abuse), 5 percent had a history of violence, compared to more than 12 percent of those comorbid for drug abuse and bipolar disorder. Some of the most important findings regarding the co-occurrence of psychiatric illness, drug abuse, and violence in the general population come from the Epidemiologic Catchment Area (ECA) surveys. This study of more than 20,000 community and institutional residents in five metropolitan areas found lifetime rates of drug abuse or dependence disorders to be as high as 47 percent among respondents with schizophrenia, 32 percent for those with major depressive illness, 56 percent for persons with bipolar affective disorder, and 87 percent for those with antisocial personality disorder (Regier et al., 1990). In data pooled from three ECA sites, about 2 percent of respondents with no disorder reported some violent behavior occurring within a one-year period. By comparison, the violence rates were 7 percent among those with a major psychiatric disorder only (schizophrenia or affective disorder) and 22 percent among those with co-occurring psychiatric and drug abuse disorders. In multivariable models that controlled for age, sex, race, socioeconomic status, and marital status, the co-occurrence of psychiatric and drug abuse disorders emerged as one of the strongest predictors of violence toward others. Certain demographic covariates also increased the risk of violence among respondents with co-occurring disorders; among younger adult males of lower socioeconomic status, who reported a history of arrest and hospitalization, the predicted probability of violent acts within one year was 64 percent (Swanson, 1994). Four mechanisms have been proposed to explain the underlying relationship between co-occurring drug abuse and psychiatric disorders and violence (Smith and Hucker, 1994). The first hypothesis is that violence in this group is linked primarily to the chemical effects of psychoactive drugs (e.g., cocaine may stimulate impulsive and aggressive behavior; alcohol may have a disinhibiting effect, possibly reducing tolerance for frustrating situations). Such effects may occur at lower doses for people with underlying psychiatric disorders (Drake et al., 1990). Antisocial personality traits often underlie both drug abuse and violence, and those antisocial traits may co-occur with psychotic disorders or other major psychiatric disorders as well. A third proposed mechanism is that drug use may exacerbate psychiatric symptoms, such as paranoid delusional beliefs, which can lead to violent actions in response to perceived threats. Finally, it has been proposed that social and economic factors—such as poverty and crime in the surrounding environment—largely account for the increased risk of violence among persons with co-occurring psychiatric and drug abuse disorders (Hiday, 1995). Limited evidence exists for each of

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Pathways of Addiction: Opportunities in Drug Abuse Research those hypotheses individually; however, no studies to date have adequately assessed all of those factors together in an effort to examine their relative and interacting effects over time on interpersonal violence. Although a sizable body of research has accumulated on selected aspects of violence, drug abuse, and co-occurring psychiatric disorders, key questions remain. They include the underlying mechanisms, developmental framework, and social context, as well as the long-term effectiveness of interventions that may be appropriate for this population. Thus, the committee urges a more comprehensive understanding of the risk factors associated with co-occurring psychiatric disorders and drug abuse and violence. Additionally, a more complete understanding of the types of interventions that may prove successful is needed. The committee recommends research on violence, drug abuse, and co-occurring psychiatric disorders. Particular emphasis should be placed on the mechanisms underlying comorbidity and violent behavior and on developing effective prevention and treatment interventions. REFERENCES Alessandri SM, Sullivan MW, Imaizumi S, Lewis M. 1993. Learning and emotional responsivity in cocaine-exposed infants. Developmental Psychology 29:989-997. Amaro H, Zuckerman B, Cabral H. 1989. Drug use among adolescent mothers: Profile of risk. Pediatrics 84:144-151. Anday EK, Cohen ME, Kelley NE, Leitner DS. 1989. Effect of in utero cocaine exposure on startle and its modification. Developmental Pharmacology and Therapeutics 12(3):137-145. APA (American Psychiatric Association). 1994. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Washington, DC: APA. Aronson M, Kyllerman M, Sabel KG, Sandin B, Olegard R. 1985. Children of alcoholic mothers: Developmental, perceptual, and behavioral characteristics as compared to matched controls. Acta Paediatrica Scandinavica 74:27-35. Bailey DN, Shaw RF. 1989. Cocaine and methamphetamine-related deaths in San Diego County (1987): Homicides and accidental overdoses. Journal of Forensic Sciences 34:407-422. Ball JC, Lange WR, Myers CP, Friedman SR. 1988. Reducing the risk of AIDS through methadone maintenance treatment. Journal of Health and Social Behavior 29(3):214-226. Bartels SJ, Teague G, Drake RE, Clark RE, Bush PW, Noordsy DL. 1993. Substance abuse in schizophrenia: Service utilization and costs. Journal of Nervous and Mental Disease 181:227-232. Battjes RJ, Leukefeld CG, Pickens RW. 1992. Age at first injection and HIV risk among intravenous drug users. American Journal of Drug and Alcohol Abuse 18(3):263-273. Battjes RJ, Pickens RW, Brown LS Jr. 1995. HIV infection and AIDS risk behaviors among injecting drug users entering methadone treatment: An update. Journal of Acquired Immune Deficiency Syndromes and Human Retroviology 10(1):90-96. Beckwith K, Parmalee A. 1986. EEG patterns in preterm infants, home environment, and later I.Q. Child Development 57:777-789.

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