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Understanding and Preventing Violence: Volume 1 (1993)

Chapter: 4 Alcohol, Other Psychoactive Drugs, and Violence

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Suggested Citation:"4 Alcohol, Other Psychoactive Drugs, and Violence ." National Research Council. 1993. Understanding and Preventing Violence: Volume 1. Washington, DC: The National Academies Press. doi: 10.17226/1861.
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ALCOHOL, OTHER PSYCHOACTIVE DRUGS, AND VIOLENCE 182 4 Alcohol, Other Psychoactive Drugs, and Violence The connections between violence and alcohol and other psychoactive drugs—primarily opiates, cocaine, amphetamines, PCP, and hallucinogens—have rarely received much weight in developing national policy. Historically, mercantilist national ambitions, tariff revenue, presumed medical properties, the ethnic and social status of users, and moral assessments of alcohol and other drug use have played more prominent roles in formulating drug policy (Musto, 1973). Even today, despite anecdotal and research support for some connections between illegal drugs and violence, and despite reports of recent dramatic increases in drug-related violent deaths, violence remains a secondary consideration in formulating federal drug policy (White House, 1990). Whether or not connections between drugs and violence are a matter of concern in formulating national policy on drugs, it seems important from the standpoint of policy on violence control to examine what is known about how violence is affected by the use of alcohol and other psychoactive drugs, by the marketing of illegal drugs, and by policy interventions to control those activities. From an intellectual perspective, studying how violence is related to psychoactive drugs is of special interest because it demonstrates so clearly the basic premise of Chapter 3—that violent events arise from interactions that cut across the biological, psychosocial, and macrosocial levels. At the biological level, pertinent neurobiologic relationships

ALCOHOL, OTHER PSYCHOACTIVE DRUGS, AND VIOLENCE 183 have been discovered between certain psychoactive drugs (including alcohol) and violence, but certainly no basis for a blanket assertion that taking any of them causes people to behave violently. To start with, each of these drugs produces its own distinct array of biological changes; their effects on the body are not alike. For any drug, the particular changes depend on the acute dose level, the long-term pattern of drug use, and whether the concentrations in the brain and body are rising or falling. How these changes affect aggressive or violent behavior depend not only on interactions with endocrine, neurochemical, and genetic mechanisms, but also on interactions with processes at the micro- and macrosocial levels. The link among alcohol, other psychoactive drugs, and violence turns out to be not an example of straightforward causation, but rather a network of interacting processes and feedback loops. In this chapter we examine patterns of violence related to the use of alcohol and other psychoactive drugs, evidence on the multiple connections that account for the relationship, and findings about the effects of interventions for controlling alcohol- and drug-related violence. To study these relationships, one would like to manipulate the variables hypothesized to be causal and to measure the change in violent behavior. Efforts to adhere to this scientific ideal are properly constrained, of course, by technical and ethical limitations on measurement and manipulation. Therefore, quite different methods are used at different levels, and available methods are limited in terms of both the precision of statements that can be made and our confidence in them. In general, our statements become less precise and more speculative as the studied behavior more closely resembles human violent behavior in the community. In contrast to pharmacological relationships, which are often studied in controlled experiments with human or animal subjects, evidence about social- level relationships between psychoactive drugs and violence is more fragmentary. It consists primarily of analyses of cross-sectional variation at different points in time (when different drugs were in vogue), a few ethnographic studies conducted during times of community transition, and facts about changes in particular communities at particular times. Necessarily, therefore, our arguments and conclusions at this level are more speculative than those at other levels. With these cautions in mind, we turn now to a discussion of patterns of violence and the use of alcohol and other psychoactive drugs.

ALCOHOL, OTHER PSYCHOACTIVE DRUGS, AND VIOLENCE 184 PATTERNS OF USE AND VIOLENCE Alcohol Situational Drinking Most studies of alcohol use and violence focus on situational relationships between episodes of drinking and violent events; in general, pre-1981 studies find alcohol use by the perpetrator or the victim immediately before more than half of all violent events (Greenberg, 1981). More recent data confirm these findings: between 1982 and 1989, the prevalence of liquor use by offender or victim in Chicago homicides fluctuated between 32 and 18 percent, while the prevalence of other drug use rose only from about 1 to about 5 percent (Block et al., 1990). The Drug Use Forecasting (DUF) program, in use in 22 cities, asks voluntary samples of felony arrestees whether they used alcohol within 72 hours before committing the crime for which they were arrested. During 1989, 59 percent of males and 53 percent of females arrested for violent Uniform Crime Reports index offenses reported such alcohol use. In a 1986 national survey of state prison inmates, the fraction who reported having used alcohol just before committing their crimes was smaller—about 33 percent for convicted rapists, robbers, and assaulters (Bureau of Justice Statistics, 1990: Table 14). The difference between arrestees and prison inmates would be expected if a disproportionate share of the alcohol-related incidents involved acquaintances who were reluctant to press charges and appear as witnesses. These prevalence data are, of course, only suggestive. They are not sufficient to demonstrate that alcohol use increases the risk of violence. Greenberg's (1981) review found substantial alcohol involvement in nonviolent crimes as well as violent ones, and alcohol use prevalence rates in the DUF samples were nearly identical for violent and nonviolent offenses. Prevalence data are not sufficient to show that alcohol use or intoxication increases the general risk of violence. To test that hypothesis with prevalence data, one would need a benchmark: the fractions of people not involved in violence or crime while drinking—with appropriate adjustments for demographic characteristics of participants, time of day, day of week, and place of occurrence. The panel has been unable to locate or construct such benchmark prevalence data. However, an array of studies discussed later in this chapter finds connections between situational drinking and aggressive or violent behavior at the biological, social, and cultural levels.

ALCOHOL, OTHER PSYCHOACTIVE DRUGS, AND VIOLENCE 185 Chronic Drinking Only a few studies exist of the relationship between chronic drinking and potentials for violent behavior. In one sample of diagnosed alcoholics, 29 percent had a history of serious violence, including weapon use and inflicting injuries requiring medical attention (Shuckit and Russell, 1984). More importantly for our purposes, comparisons show that within otherwise comparable samples, problem drinkers are more likely than others to have histories of violence. In studies of prison inmates, those classified as "heavy" or "problem" drinkers had accumulated more previous arrests for violent crimes, were more likely to have been incarcerated for a violent crime, and reported higher average frequencies of assaults than did other inmates (see review by Collins, 1986). In a sample of Finnish juvenile delinquents, Virkkunen (1974) found an arrest rate for violent crimes of 22 percent for those who had also been arrested for drunkenness, compared with 12 percent for delinquents without a drunkenness arrest; a similar differential, 47 to 36 percent, was found for property crimes. Studies of the prevalence of alcoholics among violent offenders indicate that alcoholism has been diagnosed in 20 to 40 percent of convicted murderers, 20 to 30 percent of convicted robbers, and 30 to 40 percent of convicted aggravated assaulters (Greenberg, 1981). These fractions are similar to those found among convicted property offenders. Other Psychoactive Drugs Compared with alcohol, there are relatively few sources of data on patterns of drug use and violence. These sources and studies provide the following picture: (1) In 1989, 60 percent of arrestees for violent offenses tested positive for at least one illegal drug1 —about the same fraction as those arrested for public order offenses, slightly less than those arrested for property crimes and sex offenses, and, as expected, far less than those arrested for drug offenses. (2) Users of certain drugs2 commit violent crimes at higher individual annualized frequencies than do nonusers, and violent crime frequency increases with drug use frequency. (3) The risk of drug-related homicide varies by place—from perhaps 10 percent of all homicides nationwide, to a third or more in certain cities, to more than 70 percent in high-risk areas of some cities—as well as over time, in ways that vary from area to area.

ALCOHOL, OTHER PSYCHOACTIVE DRUGS, AND VIOLENCE 186 Use Among Arrestees Data on the prevalence of drug-positive tests among arrestees are available from the DUF program, in which samples of arrestees are voluntarily tested for 10 drugs other than alcohol (see note 1). In 1989, for males and females combined, 60 percent of arrestees for violent crimes tested positive for at least one of these drugs in 1989—just a few percentage points above the fraction who reported using alcohol. Higher drug-positive rates occurred among arrestees for public order offenses (62 percent), property and sex offenses (66 percent), and drug offenses (83 percent). Compared to male arrestees, the drug-positive rates for female arrestees were 3 to 6 percent lower for both violent and property offenses, about the same for drug offenses, and 7 percent higher for public order offenses including prostitution, for which drug use is prevalent. These 1989 drug-positive rates are 1 to 5 percent lower than 1988 levels for all crime-by- gender groups. They are toward the high end of a 1986 range reported for Washington, D.C., by Wish et al. (1986) and Toborg et al. (1986). By combining data for all (violent and nonviolent) felony arrests from the 22 cities, about 20 percent of all arrestees tested positive for two or more of the drugs. By themselves, these figures are difficult to interpret. Because the urine samples are collected at the time of arrest, they convey little information about drug use at the time of the offense for persons who were not arrested at the scene —traces of drug use leave the body at different rates for different drugs. Even absent this problem, the lower prevalence of positive tests among arrestees for violent offenses compared with arrestees for other offenses would argue against the presumption that using psychoactive drugs causes violent offending. The presumption is further weakened by the conclusion of Chaiken and Chaiken (1990) that only small fractions of adolescent and adult drug users ever commit a "predatory" offense (i.e., robbery or other crime for gain). Finally, without baseline measures of the prevalence of drug users among community residents who are not arrested, one cannot assess how much more common drug use is among criminals than among others in the community. Violence Frequencies Studies of offender samples consistently find that users of certain illegal psychoactive drugs have higher individual annualized frequencies for such violent offenses as robbery, armed robbery,

ALCOHOL, OTHER PSYCHOACTIVE DRUGS, AND VIOLENCE 187 and assault than do nonusers of drugs (Blumstein et al., 1986; Chaiken and Chaiken, 1990; Cohen, 1986; Johnson et al., 1985). The relationship holds over a variety of definitions of drug use: heroin addiction and use (Ball et al., 1983; Chaiken and Chaiken, 1982); daily heroin and cocaine use; and multiple illicit drug use (Elliott and Huizinga, 1984). Because use of multiple drugs including alcohol is so common in offender populations (Wish and Johnson, 1986), available data do not permit us to relate differences in offending rates to specific drugs. Elliott and Huizinga (1984) report the only evidence that partially conflicts with this general conclusion, based on respondents to the longitudinal National Youth Survey (NYS). In 1976, multiple illicit drug users in their sample reported an average robbery incidence (7.2 per person per year) more than double that for nonusers (3.1). In 1980 the relationship was reversed: multiple illicit drug users reported an incidence of only 6.4, compared with 13.1 for nonusers. As noted by Chaiken and Chaiken (1990), this may reflect decreased participation in robbery as sample members move out of the teenage years, or the possibility that subjects who are both multiple illicit drug users and robbers may drop out of the NYS sample over time—an indication of the importance of efforts to minimize attrition in longitudinal studies. These descriptive patterns, of course, are not explanations. They are consistent with predatory offending to raise money for drugs, with individual differences or community characteristics that encourage high levels of both drug use and violent offending, and even with a pharmacological effect of drug use on behavior. These and other plausible explanations are considered later in this chapter. Drug Use and Homicide Rates Illegal psychoactive drug use and marketing are clearly implicated in a substantial share of urban homicides, but the relationship is far from the uniform, straight-line relationship claimed by some policy makers (Isikoff and Sawyer, 1990). Although estimating the fraction of all homicides classified as "drug related" involves judgments and approximations, two national estimates from the early 1980s are fairly consistent at 10 percent (Harwood et al., 1984) and 9 percent (Goldstein and Hunt, 1984) for 1980. Urban rates are higher and rose substantially during the 1980s (Goldstein, 1989). Inciardi (1989) found substantial differences in homicide trends across six cities between 1985 and 1988-1989, as their local crack

ALCOHOL, OTHER PSYCHOACTIVE DRUGS, AND VIOLENCE 188 epidemics unfolded. Homicide trends during those years varied from decreases in Detroit and Los Angeles to an increase of more than 350 percent in Washington, D.C. For the five DUF participants among the six cities compared by Inciardi, Figure 4-1 extends Inciardi's trends through the end of 1989 and relates them to DUF data on the fraction of 1989 male arrestees testing positive for cocaine, including crack. Neither the levels nor the trends of homicide rates in those cities show any consistent relationship to the prevalence of cocaine users among male arrestees. New York, with the highest cocaine prevalence of the five cities, and Los Angeles, with the second lowest, have the lowest homicide rates. The New York, Miami, and D.C. data resemble, if anything, an inverse relationship between homicide rates and arrestees' cocaine use. Clearly, the aggregate-level relationships between cocaine use and homicide trends defy simple straight-line description. Figure 4-1 Homicide rates, 1985-1989; cocaine users among male arrestees, 1989. SOURCE: Compiled in Inciardi (1989).

ALCOHOL, OTHER PSYCHOACTIVE DRUGS, AND VIOLENCE 189 PHARMACOLOGICAL LINKS BETWEEN DRUG USE AND VIOLENCE Alcohol Experimental and ethological (i.e., seminatural setting) studies demonstrate that low acute doses of alcohol temporarily increase, and high doses temporarily decrease, aggressive behavior in many animal species, including fish, lower mammals, primates, and humans. The increased aggression is associated with the generally arousing effects of alcohol in the early phases of its action; what happens during the later phases, when dysphoric effects occur, has not been well studied (Babor et al., 1983). Chronic alcohol administration to rats causes an increase in their rate of injurious aggression as a response to social provocations, and there is preliminary evidence of a similar pattern in primates. These patterns for other animals are consistent with those previously discussed for humans: high prevalence and incidence of violent crimes among diagnosed alcoholics, and a high fraction of alcoholics among violent offenders (Miczek et al., Volume 3). Conventional wisdom sometimes explains these effects in terms of disinhibiting effects of alcohol that are presumed to release aggressive impulses from inhibition by the brain. Yet the evidence from three decades of studies of animals and humans clearly demonstrates that there is no simple dose-response relationship. Rather: "whether or not alcohol in a range of doses … causes a certain individual to act aggressively more frequently or even to engage in 'out of character' violent behavior depends on a host of interacting pharmacological, endocrinological, neurobiologic, genetic, situational, environmental, social, and cultural determinants" (Miczek et al., Volume 3). These relationships are discussed in the following pages, drawing heavily on comprehensive reviews by Miczek et al. (Volume 3) and Fagan (1990). Endocrinological Interactions Statistical associations between alcohol use and human sexual violence raise the possibility that alcohol consumption might stimulate violent behavior through the endocrine system. Actually, higher alcohol doses reduce testosterone concentrations through action on the testes and liver—a process that is incompatible with the presumption (Van Thiel et al., 1988). However, in experiments

ALCOHOL, OTHER PSYCHOACTIVE DRUGS, AND VIOLENCE 190 with rodents and primates, acute low alcohol doses were found to increase aggressive behavior in individuals who already had high blood testosterone levels by more than in other individuals, presumably as a result of testosterone action in the brain. The fact that males are more likely than females to behave violently after consuming alcohol also suggests the possibility of an endocrinological interaction. However, no relevant experimental evidence exists, and correlational analyses suggest that the gender differential is likely to reflect social factors that lead males to expect greater aggression-heightening effects from alcohol than do females (Crawford, 1984; Gustafson, 1986a, b). Neurobiologic Interactions Many neurobiologic explanations have been offered for the effect of alcohol on the central nervous system. At least a few of these are consistent with nonexperimental evidence and relate specifically to aggressive or violent behavior, but none has been confirmed through experiments. In one sample of violent Finnish alcohol abusers, abnormally low cerebrospinal fluid concentrations of the serotonin metabolite 5- hydroxyindoleacetic acid (5-HIAA) were correlated with poor impulse control (Linnoila et al., 1983; Virkkunen et al., 1989a, b). But this correlation could reflect either that poor serotonergic functioning interacts with alcohol to cause violent behavior, or that chronic alcohol abuse interferes with serotonergic functioning simultaneously with other effects on potentials for violent behavior. Low serotonin metabolism appears to be linked to a low response to glucose challenge tests in alcoholic violent offenders, suggesting a possible interaction among predispositions toward violent behavior, alcoholism, and hypoglycemia. In recent animal experiments, pharmacologically blocking the GABAA / benzodiazepine receptor complex inhibited several common behavioral effects of alcohol, including stimulating aggressive behavior in rats and monkeys (Weerts et al., in press). These findings suggest that the GABAA/benzodiazepine receptor complex may be involved in the aggression-heightening effect of alcohol doses. Future studies of the GABAA/benzodiazepine receptor complex need to examine its role in promoting human aggression under the influence of alcohol. Some evidence also suggests alcohol is related to violent human behavior through effects on electrical activity in the brain. In one small sample of people who had committed a violent or

ALCOHOL, OTHER PSYCHOACTIVE DRUGS, AND VIOLENCE 191 antisocial act, alcohol doses produced an electroencephalogram (EEG) abnormality consistent with temporal lobe damage that is aggravated by the alcohol (Marinacci and von Hagen, 1972). A more recent study found a reduced P300 component of event-related potentials in violent but not nonviolent alcoholics (Branchey et al., 1988). Genetic Interactions There are consistent demonstrations of genetic bases for alcohol abuse (Goodwin, 1973) and for antisocial personality (Schubert et al., 1988), a psychiatric category for which some of the diagnostic criteria are violent behaviors. The fact that they frequently co-occur raises the possibility of some common elements in their genetic bases. Whether the two bases are independent or not is in controversy, with Cadoret et al. (1985) claiming independence and Cloninger et al. (1989) claiming a link for one subtype of alcoholic. One recent study (Grove et al., 1990) involved too small a sample to reach firm conclusions, and, surprisingly, the panel could find no relevant animal studies of this issue. Other Psychoactive Drugs Biological links between psychoactive drug use and violence differ by type of drug, amount, and pattern of use. Use of marijuana or opiates including heroin in moderate doses temporarily inhibits violent and aggressive behavior in animals and humans. In animals, withdrawal from opiate addiction leads pharmacologically to heightened aggressive and defensive actions that last beyond other physiological withdrawal symptoms. Although the same may be true of humans, performing comparable research on addicted human subjects is complicated by multiple pharmacological, conditioning, and social processes that are difficult to disentangle. Chronic use of opiates, amphetamines, marijuana, or PCP eventually alters the nervous system in ways that disrupt social communications—an effect that may increase one's involvement in altercations that escalate to violence. Amphetamines, cocaine, LSD, and PCP resemble one another in terms of their pharmacological links to violent behavior. Small acute doses increase competitiveness, volubility, and other socially acceptable aggressive behaviors, but are not known to increase the risk of violent behavior. Higher doses seem to cause generally disorganized behavior, including occasional violent outbursts

ALCOHOL, OTHER PSYCHOACTIVE DRUGS, AND VIOLENCE 192 in a subset of individuals. Long-term frequent use may change the nervous system in ways that induce psychosis, and violent behavior sometimes occurs during drug-induced psychosis. But the frequency of such episodes varies from sample to sample and seems highest among drug users with preexisting psychopathology. These findings are developed further in the following pages. (See Miczek et al., Volume 3, for more complete discussion and supporting citations.) Opiates Doses of morphine and other opium derivatives temporarily reduce aggressive behavior in animals and violent behavior in humans, according to a large number of studies. While occasional heroin use offers humans the feeling of well-being, chronic use affects mood and behavior in more complex ways. Chronic use reduces social interactions in animals and often leads humans to feelings of confusion, hostility, and suspicion; these in turn may increase the risk of violent behavior in future interactions. Chronic use of opiates leading to addiction also modifies the neuroreceptors for opioid peptides—opiate-like chemicals produced within the body. Studies of rodents, cats, and primates in the last decade have shown that such long-term alteration impairs the animals' abilities to communicate while under stress. Extrapolating this relationship to humans, the addiction effect could disrupt individuals' social communications in ways that increase their risks of violent behavior or victimization during subsequent stressful interactions. Animal studies over 25 years have demonstrated that withdrawal from opiates increases the probability of heightened aggressive and defensive acts that continue after other withdrawal symptoms have subsided. Studies of rodents indicate that brain dopamine and noradrenergic receptors undergo marked changes during withdrawal from opiates. This suggests that drugs such as clonidine may be useful in managing human aggression during withdrawal from heroin, and clinical evidence in humans provides some support. Relationships involving opiate addiction, withdrawal, and violent behavior may be amplified by preexisting feelings of rage among heroin addicts. Elevated prevalences of these feelings in opiate addicts have led some to theorize that some persons may become addicted in the course of seeking relief from feelings of

ALCOHOL, OTHER PSYCHOACTIVE DRUGS, AND VIOLENCE 193 rage. A return of those feelings during withdrawal could precipitate violent behavior. Amphetamines Since the first amphetamine was synthesized in 1887, a number of varieties have been developed and used to fight fatigue, enhance endurance, suppress appetite, and alter moods. The class includes drugs such as dextro- and levo- amphetamine, and d-methamphetamine, which are available as appetite suppressants as well as illegally produced and distributed drugs such as “ice" (smokable methamphetamine), "eve" (MDA), and "ecstasy" (MDMA). Their effects on the nervous system and on violent and other behaviors have been studied using both animal models and human subjects and clearly depend on the level and long-term pattern of intake. At acute low doses amphetamines increase aggressive and defensive behaviors in fish, pigeons, mice, rats, cats, and monkeys. This effect is most apparent during withdrawal from opiates and under habituation to aggression- provoking conditions, and enhanced aggressive behavior is most apparent in socially dominant animals. In humans, low amphetamine doses are associated with enhanced volubility and competitiveness but not necessarily with increased risk of violent behavior. Findings from clinical experience, laboratory experiments, and self-reports highlight the euphoria produced by low doses of amphetamines, but also note occasional cases of anxiety. Although available data do not permit one to construct dose-response curves for amphetamine use by animals or humans, higher doses do not seem to simply amplify the behaviors observed at low doses. Rather, intermediate doses are associated with increased defensiveness and general disorganization of animals' social behaviors, including not only pursuit, threat, and attack, but also copulatory, maternal, and other social interactions. Analogously, human users display less impulse control at higher doses. Chronic administration of amphetamines to animals causes social withdrawal and eventually heightened threat and defensive reactions. It is tempting to interpret these as analogues to paranoia and psychosis, which are well documented in human chronic amphetamine users and are sometimes accompanied by serious violent outbursts. While the occasional occurrence or seriousness of violent behavior during amphetamine-related psychosis is not in doubt, its prevalence varies across samples, ranging from perhaps

ALCOHOL, OTHER PSYCHOACTIVE DRUGS, AND VIOLENCE 194 10 percent among chronic users in the general population to perhaps two-thirds among users with preexisting psychopathology. Thus, while chronic amphetamine use seems more closely related to violent behavior than is use of other psychoactive drugs, the strength of the relationship depends on the user's prior psychiatric condition. The neurochemical mechanisms for amphetamine's effects on aggressive and violent behavior remain to be identified. While acute amphetamine doses mimic the effect of stressful external stimuli in releasing dopamine and norepinephrine within the brain, and some aspects of amphetamine psychosis are successfully managed by antipsychotic drugs that block dopamine receptors, these drugs do not reverse the disruption of social behavior, and massive incapacitating doses are required to decrease violent behavior associated with chronic amphetamine use. Cocaine The limited pharmacological and psychiatric literature has not yet established direct neurobiologic links between violent behavior and acute or chronic cocaine use. Chronic use in powdered or smokable ("crack") form sometimes leads to paranoid or psychotic states, in which violent or aggressive behavior may sometimes occur. Such cases were observed in 6 percent of all cocaine-related emergency department admissions in one hospital over a two- year period. However, another study reported no difference in the frequency of violent acts between institutionalized cocaine users and other inpatients. Information is urgently needed to determine whether the rapid access of smoked cocaine to the brain produces distortions in the perceptions of social signals and a particular propensity to engage in violent behavior. In mice, rats, and monkeys, acute cocaine intake increases defensive reactions to stress but disrupts aggressive behavior. Even chronic cocaine treatment did not increase aggressive behavior in several species. Thus, the animal literature is quite consistent with the finding of Goldstein et al. (1989) that homicide arising from the pharmacological effects of cocaine is fairly rare. Hallucinogens The drugs in this category are chemically diverse. They include cannabis in various forms (marijuana, hashish, bang), phencyclidine, and LSD.

ALCOHOL, OTHER PSYCHOACTIVE DRUGS, AND VIOLENCE 195 During the past two decades, five major scientific reviews of the research literature have concluded that violent human behavior is either decreased or unaffected by cannabis use. Similarly, studies of many animal species demonstrate that acute doses of THC, the psychoactive ingredient in marijuana, promote submissive and flight responses and, at least in large doses, inhibit attack and threat behavior. These effects persist during chronic administration to the animals. According to clinical reports, violent behavior occurs at least occasionally in persons who are either under the influence of acute doses of phencyclidine (PCP, "angel dust") or experiencing psychosis brought on by long-term use of the drug. The frequency of such events among PCP users is unknown. No experimental studies of PCP and human violence have been conducted, and spontaneous PCP use usually accompanies use of alcohol or other drugs with confounding neurobiologic effects. Therefore, the pharmacological effects of human PCP use are not yet well understood, and specific drugs to control violent behavior that occurs under the influence of PCP are not yet available. In animal experiments, PCP doses have increased some aggressive behaviors under certain conditions; but the more uniform consequence is that the animals treated with PCP become the targets of aggression by other animals, presumably because the PCP triggers inappropriate social signals, provocative actions, and hyperactivity. The pharmacological relationship between LSD and violent behavior was studied fairly intensively several decades ago. Studies of humans suggest that LSD use does not trigger violent behavior but does sometimes aggravate the effects of preexisting psychopathology, including violent outbursts. LSD doses have been observed to increase aggressive, defensive, and timid reactions in different animal species, suggesting a possible heightened sensitivity to social and environmental stimuli generally. PSYCHOSOCIAL LINKS BETWEEN DRUG USE AND VIOLENCE There is fairly strong evidence that individual differences beyond the biological processes discussed above intervene in the relationships between violent behavior and the use of alcohol and other psychoactive drugs. For example, the experimental statistics that demonstrate the basic alcohol dose relationship—heightened aggression at low doses and reduced aggression at high doses—demonstrate variation across individuals. At any dosage within the low- dose range, while most individuals are experiencing heightened

ALCOHOL, OTHER PSYCHOACTIVE DRUGS, AND VIOLENCE 196 aggression, a few are experiencing reductions. An analogous scattering of individual responses occurs in the high range. Gender appears to be of fundamental importance in modifying the relationship between alcohol use and violent behavior. National surveys report that male drinking patterns are more likely than those of females to incorporate binge drinking and aggressive behavior, and that violent behavior while under the influence of alcohol is very rare among females (Blane and Hewitt, 1977; Cahalan and Cisin, 1976; and Gandossy et al., 1980, all cited in Fagan, 1990). Identifying the biological, expectational, and social factors that account for this differential behavior remains a question for future research. Additional evidence of differences is the finding that individuals' histories of aggressive and violent behavior are a critical determinant of whether or not alcohol and psychoactive drug use increases those behaviors. The finding recurs in studies of animals (Pettijohn, 1979; Miczek and Barry, 1977) and of humans (Rydelius, 1988). In experimental studies of mice, rats, and monkeys, alcohol doses that more than doubled the average rate of threat and attack behavior in animals that had previously exhibited these behaviors had no effect in animals who had previously behaved in primarily submissive and defensive ways (Blanchard et al., 1987; Winslow and Miczek, 1985; DeBold and Miczek, 1985). There is also correlational evidence from longitudinal studies of humans that the links between chronic alcohol use and aggressive or violent behavior remain fairly stable through the developing years into adulthood. Studies demonstrate that childhood aggression is a risk factor for both heavy drinking and violent behavior in young adulthood (Pulkkinen, 1983). McCord (1983, 1988) found that the combination of early childhood aggressiveness and alcoholism as an adult predicted high levels of violent behavior. Studies framed within a medical model are consistent with these findings. Miczek et al. (Volume 3) point to two subcategories of dually diagnosed personality disorders that have been found to have elevated risks of violent behavior: alcoholics diagnosed as sociopathic (O'Leary et al., 1978; Yates et al., 1987) and individuals diagnosed with antisocial personality disorder who abuse both alcohol and other psychoactive drugs. The latter group may form a specific genetic subtype (Cloninger, 1987). Although questions have been raised about the validity of these diagnostic categories and the distinction between them, the findings are consistent with those of the longitudinal studies.

ALCOHOL, OTHER PSYCHOACTIVE DRUGS, AND VIOLENCE 197 Identifying a link between specific childhood behaviors or personality disorders and adult violent behavior under the influence of alcohol or other drugs does not explain episodes of such behavior in adults without either of the disorders. Theoretical and clinical literature reviewed by Fagan (1990) points to specific emotions that often precede or accompany aggressive behavior—hate, rage, shame, guilt, helplessness, and dependence—and suggests that these may be related to the consumption of alcohol or other psychoactive drugs in any of several ways. First, users may select specific drugs to dampen or intensify certain emotions. Wurmser and Lebling (1983, cited in Fagan, 1990) report case studies in which cocaine and Methedrine temporarily diminished feelings of helplessness and dependence; barbiturates and opiates reduced feelings of rage, despair, and loneliness; and stimulants, hallucinogens, and alcohol were used to dampen feelings of depression, guilt, shame, and helplessness. Second, social processes such as family arguments that are associated with substance abuse (e.g., spending too much money on alcohol or drugs) may trigger the violent behavior. Third, both the violence-related emotions and the substance abuse may grow out of some underlying developmental or family pathology. Possibilities found by Fagan (1990) in the literature include a divergence at some developmental stage between social expectations and personality development; and compulsive masculinity during adolescence, which could encourage displays of both drug use and aggressive behavior. There is no consensus as yet on any of these explanations for the co-occurrence of violent behavior and alcohol and drug abuse that is consistently found in longitudinal studies (McCord, 1983, 1988; Elliott and Huizinga, 1984). SOCIAL-LEVEL LINKS BETWEEN DRUG USE AND VIOLENCE Researchers have discovered a few characteristics of encounters involving the consumption of alcohol, and of the places in which they occur, that seem to increase the probability of a violent event. Although developing a risk profile for such encounters might be feasible using case control methods, the panel is aware of no such effort. Even less is known about encounters involving the consumption of illegal drugs because research access is difficult to obtain. Violence during encounters in the course of marketing illegal drugs is discussed in a later section of this chapter. In an encounter between individuals, immediately prior consumption of alcohol, amphetamines, PCP, or cocaine disrupts behavior

ALCOHOL, OTHER PSYCHOACTIVE DRUGS, AND VIOLENCE 198 in ways that may increase the chance of disputes or aggravate their consequences: appraisal of the consequences of behavior, the sending and receiving of socially significant signals, and threat attribution. These disruptions can accelerate exchanges of threats and violent behaviors, which may help to account for the previously noted high prevalences of blood alcohol in both perpetrators and victims of violence. In this section we discuss three categories of social-level interactions between violence and the use of drugs: (1) striking differences across cultures and subcultures in patterns of alcohol use and violence, which have not yet been explained in terms of specific cultural features; (2) indications of frequent serious violence associated with obtaining and distributing illegal drugs; and (3) fragmentary evidence that is consistent with less direct, more speculative links between violence and the distribution and use of illegal drugs. Cultural Differences in Alcohol Use and Violence In studies of cultural differences in patterns of alcohol use and violence reviewed by Miczek et al. (Volume 3) and Fagan (1990), positive associations between alcohol use and violence have been reported in many countries populated by Europeans and their descendants: Australia, Finland, Sweden, South Africa, Canada, and the United States. However, studies of non-European cultures do not uniformly find similar connections. In a review of ethnographic reports from 60 small-scale and folk societies, Schaefer (1973) reported that men frequently get drunk in 46 of them but routinely participate in drunken brawls in only 24. Similarly, MacAndrew and Edgerton's (1969) accounts of Western Hemisphere tribal societies reported that drinking parties transform members of the normally tranquil Abipone tribe into combative individuals but cause the normally aggressive, head-hunting Yurunas to withdraw socially. Several explanations have been suggested for such differences (Fagan, 1990). First, some ethnographic reports attribute them to cultural norms or customs. For example, male members of the Camba tribe of subsistence farmers go on rum-drinking binges twice a month, but aggression during or between those periods is virtually nonexistent. In contrast, lethal knife fights are common during similar binges by Finnish Lapps, who are not abnormally violent when sober (Heath, 1983). Intoxicated Navajo fight almost exclusively with family members. And Plains Indian men

ALCOHOL, OTHER PSYCHOACTIVE DRUGS, AND VIOLENCE 199 are expected to fight when intoxicated as young men, yet older "family men" are expected to avoid violence when intoxicated. Despite these general tendencies, behavioral differences across individuals and situations within any single culture suggest that the cultural pattern explanation is incomplete. Second, some cultures within larger societies may use intoxication to excuse or to embolden violent and other behaviors that are unacceptable to the larger societies. For example, the high rate of violent deaths and alcohol abuse among Native Americans has been interpreted as part of a coping strategy to deal with problems that arise during acculturation into white society (Westermeyer and Brantner, 1972; Seltzer, 1980). Studies of California gangs suggest that Hispanic and black gangs may use alcohol to achieve different behavioral states—Hispanic gang members seeking a rather frenzied locura, blacks seeking a reserved cool —both of which facilitate violent behavior (Vigil, 1987, 1988; Feldman et al., 1985, cited in Fagan, 1990). Third, some studies suggest that the alcohol-violence connection in any culture depends on the stresses placed on members of that culture by the social structure. The aggressive drinkers among Naskapi men in northern Canada were reportedly the least successful iron miners—though the cause-effect relationship is unclear (Robbins, 1979, cited in Fagan, 1990). Gordon (1978, cited in Fagan, 1990) reported that Dominican immigrants to the United States brought their whole families, found greater economic opportunity, changed their drinking locations from bars to homes, and reduced their aggression. He found the opposite experience with drinking and aggression among Guatemalan men, who left their wives at home and lived without the company of women (Gordon, 1982, cited in Fagan, 1990). Finally, the effects of alcohol on human behavior may be modified by expectations about those effects (Miczek et al., Volume 3; Levinson, 1983, cited in Fagan, 1990). As noted by Fagan (J. Fagan, personal communication, February 15, 1990), one ethnographic study suggests that even intoxicated people's behavior during encounters may be constrained by their awareness of social expectations. Over the course of an evening of drinking and socializing with four male adolescents, Burns (1980) reported them to be quiet and deferential when surrounded by their elders in a familiar neighborhood tavern, but more aggressive (including threats with a gun) in other surroundings. The causal mechanism may well be reciprocal. Burns speculated that his subjects' drinking heightened their aggressiveness, which caused them to search for locations

ALCOHOL, OTHER PSYCHOACTIVE DRUGS, AND VIOLENCE 200 more conducive to its expression, where in fact they did express it. There is a need for more rigorous research, involving larger samples, to test alternative explanations. Clearly, patterns of drug and alcohol use and violent behavior differ across cultures and subcultures. But the patterns can apparently be modified, despite the difficulty of ascertaining what features of a given culture account for the pattern there. Obtaining and Distributing Illegal Drugs The illegality of some psychoactive drugs raises their street prices above the levels that would exist in an open market. The raised price is associated with two different kinds of encounters, each of which carries a risk of violence. First, some drug users commit robberies or burglaries3 to obtain drugs or money for purchasing drugs. Second, the artificially raised prices create excess profits for drug dealers, which raises the stakes in disputes about marketing practices. Since these illegal markets are not subject to legal dispute resolution mechanisms, violence may be a first resort. Goldstein et al. (1989) designated the first type of violence economic and the second systemic. To assess their relative frequency, he and his colleagues classified the police records of 414 homicides that occurred between March and October 1988 in selected precincts of New York City. They classified 53 percent of the homicides as drug related: 39 percent systemic, 2 percent economic, 8 percent due to the pharmacological effects of drugs, and 4 percent multiple cause. This effort was valuable in demonstrating the difficulty of defining drug- related violence. It demonstrated that multiple factors interact in more complex ways than a simple classification scheme would suggest. Also, the researchers found that they applied the scheme quite differently than the police officers who had prepared the case reports—particularly in designating the "causal" factor(s). Officers and researchers both classified more drug-related events as "systemic" than any other category, but the officers used the "economic" category far more often than did the researchers (Ryan et al., no date). The inconsistency suggests that inferring causality in a particular case is difficult and subjective, especially when multiple causal factors are present in an event.

ALCOHOL, OTHER PSYCHOACTIVE DRUGS, AND VIOLENCE 201 Economic Violence In his analysis of New York City homicides, Goldstein et al. (1989) classified as economic only the 2 percent that occurred in the course of "economic crimes in order to finance costly drug use"—primarily robberies and burglaries. This figure understates the role of economics in drug-related violence for several reasons. First, the drug motivation for a robbery or burglary is often concealed, or at least slow in coming to light. Second, the classification excludes at least two kinds of economically motivated violence. Homicides in the course of illegal drug marketing to support drug use (e.g., a robbery of drugs from a dealer in which the user or dealer is killed) were counted as drug related but classified as systemic. But violence in the course of economic crimes with indirect drug-related motivation—a robbery to obtain grocery money after spending the intended grocery money on drugs—was not counted as drug related. A body of research concurs that, except during withdrawal periods, heroin users in need of funds tend to avoid violent crimes if nonviolent alternatives such as burglary are available (Anglin and Speckart, 1988). Despite users' general aversion to violence, robbery by heroin users is common, and users are prevalent among robbers (Blumstein et al., 1986; Chaiken and Chaiken, 1990; Goldstein, 1989). Economic drug-related violence has been less clearly demonstrated among adult users of other illegal drugs, although Inciardi (1980) found similar patterns of robbery by young users of heroin and other illegal drugs. In part, the lack of evidence reflects a scarcity of pertinent studies. However, the low prevalence of economic drug-related violence reported by Goldstein may also reflect access to other sources of income among users of cocaine and synthetic psychoactive drugs. Cocaine and crack dealing offer attractive alternatives to robbery or burglary as a means of financing purchases. Also, wholesalers distribute crack to street dealers on a consignment basis, and the negotiated reimbursement is usually set to allow for some personal use by the retailer. In addition, Reuter et al. (1990) estimated median earnings in 1985-1987 for street-level crack dealing in Washington, D.C., at $30 per hour—a supplement to legal income for more than two-thirds of the persons arrested for illegal drug sales during that period. The growth of earnings opportunities in crack marketing may help to explain the fact that, although sales and use of cocaine (including crack) in the District of Columbia grew rapidly between 1981 and 1987, the annual

ALCOHOL, OTHER PSYCHOACTIVE DRUGS, AND VIOLENCE 202 number of reported property crimes including robbery decreased by more than 20 percent, from 53,870 to 42,783. In short, while economic drug-related violence is almost certainly more common than Goldstein's estimate of 2 percent would suggest, its importance is apparently specific to expensive dependence-producing drugs and therefore declining as smokable crack replaces heroin as the drug of choice, and crack selling becomes a source of substantial income. Systemic Violence Systemic drug-related violence can be expected to resemble violence associated with other illegal markets, such as prostitution, loan-sharking, alcohol during Prohibition, and black markets in other prohibited goods. It was the most common form of drug-related violence, according to Goldstein et al.'s (1989) analysis. Available knowledge about the circumstances surrounding systemic violence comes mostly from ethnographic or interview studies (Johnson et al., 1985; Fagan, 1989; Hamid, 1990; Bourgois, 1989; Mieczkowski, 1989; Chin, 1990). Systemic drug-related violence takes three distinct paths. Organizational systemic violence includes territorial disputes with rival organizations over drug distribution rights; the enforcement of organizational rules, such as prohibitions against drug use while selling or trafficking; battles with police; punishment of individual officers, informers, or antidrug vigilantes; and efforts to protect drugs or sellers. Of these, territorial disputes were found most common in both the Goldstein and the Chin studies. Transaction-related systemic violence includes robberies of drugs or money from the seller or the buyer during a transaction, assaults to collect debts, and the resolution of disputes over the quality or quantity of drugs or over paraphernalia ownership or rights. Both the New York City studies report that of these, robberies of dealers and assaults to collect debts are more common than the other circumstances listed here. Another common violence provocation in illegal drug marketing, termed "messing up the money," occurs when a lower-level dealer fails to return the agreed-upon amount of money after disposing of his drug consignment. Because the discrepancy may occur through personal consumption, theft or loss of the drugs, robbery or personal use of the money, or other illegal acts, the resulting dispute can rarely be settled with evidence and often leads to violence. Systemic violence involving third parties can involve bystanders

ALCOHOL, OTHER PSYCHOACTIVE DRUGS, AND VIOLENCE 203 to drug disputes; participants in related illegal markets such as protection rackets, firearms, and hired “enforcement"; and prostitutes who also sell or use crack. This kind of violence is especially difficult to study safely, so little is known about it. Sherman et al. (1989) found that, although shootings of bystanders increased in four large cities between 1977 and 1988, they accounted for less than 1 percent of all 1988 homicides in those cities, and drug market conflicts were only one of several causes of bystander shootings. Data on the frequencies of these subcategories of systemic violence are fragmentary and subject to question. There is need for more systematic counting of their occurrences and analysis of the frequency of their occurrence in different settings. Social and Indirect Drug-Related Violence To this point, our discussion of social-level links between illegal drugs and violence has been limited to purchases and distribution. Social interactions that are less obviously drug related may also be involved, as well as the interaction of technological change in illegal drug marketing with broader socioeconomic trends. First, illegal drug markets are magnets for risk-seeking persons carrying weapons and valuables and for potential victims. It seems clear that violent drug market participants behave violently outside the drug market as well (Inciardi, 1989; Fagan and Chin, 1989a,b, 1991). While the extent to which violent participants select themselves into drug market locations is unclear, ethnographic studies demonstrate that the markets create opportunities for violence that are only indirectly related to drug marketing. Sellers carrying drugs and buyers carrying money are attractive targets for robbery. Weapons brought to the marketplace out of fear are readily accessible during disputes over nondrug matters. Female buyers, whose drug habits may have drawn them into prostitution, are targets for sexual assaults. In general, greater numbers of market participants make these and similar violence opportunities more common. However, findings about prostitution operations suggest that off-street marketing environments—through appointments with beepermen or in crack houses—may reduce the hazards of drug transactions. Second, disputes over the consequences of drug use can involve violent events that are related only indirectly to the use or sale of drugs and so may not be classified as drug related. This possibility was illustrated above by a robbery of grocery money to replenish

ALCOHOL, OTHER PSYCHOACTIVE DRUGS, AND VIOLENCE 204 funds spent on illegal drugs. In-depth interviews or ethnographic observation may be needed to discover the drug connection in some disputes that turn violent— over strained family finances, too many nights away from home, careless job or school performance, or other problems that may or may not be consequences of drug use. The incidence of violent events with a hidden connection to illegal drugs is unknown. Third, there is reason to ask how youth gangs and systemic drug-related violence are related. It seems unlikely that the nationwide explosion of crack- related violence is accounted for by long-standing youth gangs with violent traditions that have adopted crack dealing as a new source of funds (Klein et al., 1988; Inciardi, 1989). Rather, the perceived increase in gang-related crack violence during the 1980s appears to result from a combination of real and artifactual causes. Apparently, some traditionally violent youth gangs in some cities did turn to crack sales as a source of income. Elsewhere, profit-seeking organizations selling crack sprang up, and researchers and criminal justice officials categorized them together with traditional youth gangs despite their distinct orientation. However, some of the perceived increase in crack-related violence was apparently artifactual—attributable to the activities of gang members acting on their own or to coincidences between independent trends in crack sales and in gang violence. The diversity noted by Fagan (1989) suggests that as a means of reducing violence, selective attention to the specific gangs that have a history of violence may be more effective than general attention to crack- selling gangs on the supposition that they are likely to be involved in violence. A fourth possibility is a breakdown of violence-inhibiting social control mechanisms in the communities that surround illegal drug markets. The violence surrounding crack may be related to large-scale social changes that have interacted with the economic, social, and organizational context of crack marketing and use (J. Fagan, personal communication, February 15, 1990; Fagan and Chin, 1989a). In contrast to earlier times, crack and cocaine marketing during the 1980s became a highly decentralized and visible activity in neighborhoods that lacked legitimate economic opportunities. The boundary between sellers and users disappeared, and easy unregulated access into the market at all levels replaced the stable system whose complex rules and territorial franchises had been enforced by crime organizations (Johnson et al., 1985, 1990; Sampson, 1987; Adler, 1985; Murphy et al., 1989). Outmigration of stable families and individuals with ties to the

ALCOHOL, OTHER PSYCHOACTIVE DRUGS, AND VIOLENCE 205 legitimate economy had already weakened neighborhood social controls against violence. The few remaining "old heads" who had acted as community social monitors lost respect because of their reduced economic status and became too intimidated by the crack market participants to exercise their moral authority (Anderson, 1990). The emergence of visible, violent crack markets hastened these processes and further weakened social inhibitors of violence in all contexts, including the drug market (Hamid, 1990; Goldstein et al., 1987). In this view, removing drug markets is useful as an intervention to control violence only to the extent that their elimination facilitates restoring social institutions and legitimate economies in the afflicted communities. Although empirical tests of this theory against alternatives are virtually impossible to carry out, individual-level studies by Fagan and Chin (1989a,b, 1991) seem to rule out some alternative explanations—some "new breed" of violent juveniles, or more violent rules in crack markets than in other contemporary drug markets—at least in certain areas of New York City. Their findings are consistent with the possibility that other factors—perhaps community-level social and economic processes—account for the variation in violence levels related to crack distribution. These relationships are extremely difficult to verify and measure. But even though they are speculative, raising them as possibilities seems preferable to discounting them as possible explanations of the perceived rise in "drug-related violence." In raising them, we hope to stimulate research that would test these hypotheses more rigorously and estimate their empirical significance more precisely. Such findings would contribute to more informed development of policies for controlling drug-related violence. INTERVENTIONS TO REDUCE DRUG-RELATED VIOLENCE The preceding discussions suggest four kinds of interventions that should be considered for reducing levels of violence related to alcohol and other psychoactive drugs: (1) biological interventions: through pharmacological treatments to reduce craving for illegal drugs or to manage heightened tendencies toward aggressive behavior associated with alcohol and the withdrawal stage of heroin use; (2) developmental interventions: through cognitive-behavioral interventions intended to prevent children from initiating use of psychoactive drugs; (3) individual-level interventions for adults: to incarcerate drug-using

ALCOHOL, OTHER PSYCHOACTIVE DRUGS, AND VIOLENCE 206 offenders and to terminate or reduce drug use through a variety of treatment techniques; and (4) community-level interventions: increases in alcohol excise tax rates, and police tactics intended to disrupt illegal drug markets. The following pages review available evidence on the effectiveness of these intervention strategies in reducing levels of drug-related violence. Biological Interventions For most illegal psychoactive drugs, the strongest links to violence are through users obtaining the money needed to purchase illegal drugs and through violence associated with drug distribution. The most effective pharmacological intervention into these links is likely to be therapeutic medication that reduces craving for drugs. For heroin users, methadone and LAAM have long been used for this purpose; on average, heroin-dependent persons have better outcomes, in terms of drug use and other criminal behavior, when they are treated with methadone than when they are not (Gerstein and Harwood, 1990:153). For other illegal psychoactive drugs, no therapeutic medication to reduce drug craving is currently in widespread use. The most promising avenues of research for developing such medications involve blockers of dopamine and norepinephrine receptor subtypes. Because alcohol use and heroin withdrawal are associated with heightened tendencies toward aggression by some individuals, medications that target specifically the violence-promoting effects of these substances would be useful. However, they do not currently exist and, as far as we know, are not under development. In animal studies, clonidine has been found to reduce aggressive behavior during withdrawal from heroin, and clinical trials should be mounted to test its effectiveness for humans in withdrawal. Since it seems fairly clear that the GABA A/benzodiazepine receptor complex is one site involved in the aggression-promoting effects of alcohol, development of a medication to block that action appears to be a promising strategy for reducing alcohol-related violence. Because alcohol affects so many biological processes, other sites should be explored as well. As noted by Miczek et al. (Volume 3), long-term basic research is needed to identify categories of individuals in whom psychoactive drugs do promote violent behavior, attending to pharmacological conditions at the time of the violent act; individuals' physiological and psychological characteristics; their genetic, developmental,

ALCOHOL, OTHER PSYCHOACTIVE DRUGS, AND VIOLENCE 207 and social backgrounds; and prevailing social conditions. Research on possible violence-promoting effects of smoking crack cocaine should also receive high priority. Developmental Interventions Based on the preceding discussion, successful substance abuse prevention during childhood shows promise of reducing violence levels through two distinct routes. First, interventions that discourage alcohol use may prevent alcohol- related violent behavior, especially by aggressive children who may later enter one of two high-risk dual diagnosis categories: (a) alcoholic/sociopathic and (b) antisocial personality disorder coupled with abuse of both drugs and alcohol. Second, because violent events occur so frequently in illegal drug markets, successful drug abuse prevention may eventually reduce violence levels by reducing the number and size of these markets. The most common strategy for substance abuse prevention to date has involved school-based programs intended to discourage 11- to 14-year-olds from taking up the use of tobacco, alcohol, marijuana, and other drugs. The general approach is to teach youngsters not only the health effects and other consequences of using these substances, but also techniques for resisting peer pressure to use them. Variations have been developed that begin education as early as kindergarten. Also, at least two programs, DARE in Los Angeles and SPECDA in New York City, have brought police officers into the classrooms to help in teaching (DeJong, 1986). In an assessment of available evidence from evaluations of the effectiveness of community-based and school-based drug abuse prevention programs, the National Research Council (Gerstein and Green, 1992) concluded that some interventions have succeeded in delaying initiation of tobacco, alcohol, and marijuana use among youth. To the extent that these substances are stepping stones to other psychoactive drugs, some prevention strategies may also help to reduce the number of users or delay the onset of use of these other illegal drugs. Despite the number of rigorous evaluations of preventive interventions over the years, the overall effectiveness of these strategies in reducing psychoactive drug use has yet to be documented. Evaluating the effectiveness of community-based and school-based interventions in reducing illegal drug use and its contribution to violent behavior should be a high priority.

ALCOHOL, OTHER PSYCHOACTIVE DRUGS, AND VIOLENCE 208 Individual-Level Interventions for Adults Incarceration of Drug-Using Offenders The strategy of selectively longer incarceration terms for convicted offenders with histories of drug use (and other characteristics associated with higher offending frequencies) was considered in depth by the Panel on Research on Criminal Careers (Blumstein et al., 1986). Despite drug users' higher average frequencies of violent crimes such as robbery and assault, that panel concluded that such selective strategies would have minimal effects on violent crime levels without massive increases in prison populations. No recent findings suggest a contrary conclusion. Because arrestees with drug use histories are more likely to be rearrested before trial if released on financial or nonfinancial conditions, a plausible related strategy is to make drug use monitoring through urinalysis a condition of pretrial release, with positive test results considered grounds for returning the defendant to jail. A randomized experimental test of this strategy in the District of Columbia offered only statistically insignificant evidence that negative urine tests predict lower pretrial rearrest rates,4 but failure to show up for the test was a strong positive predictor of pretrial rearrest for new crimes. Substance Abuse Treatment After working primarily with heroin addicts from the 1960s until the early 1980s, residential therapeutic communities have extended their programs to cocaine abusers over the past decade. Their approach—a highly structured residential process of resocialization, behavior modification, progressive responsibility, and planned reentry into the community—is perhaps the treatment most widely applied today to drug abusers with serious criminal histories. Randomized experiments have so far proven impracticable as a means of evaluating the effectiveness of such programs, so the best available evidence is based on nonrandomized studies of persons seeking admissions. The Institute of Medicine (IOM) concluded that clients of therapeutic communities show less criminal activity during treatment and after discharge than before admission, and that the minimum retention period needed to obtain this benefit is at least 3 months, with further improvement through 12-18 months (Gerstein and Harwood, 1990:15). For drug abusers in prison, drug abuse treatment usually consists of individual or group psychotherapy a few times a week

ALCOHOL, OTHER PSYCHOACTIVE DRUGS, AND VIOLENCE 209 with no postrelease follow-up. Not surprisingly, such treatment is not sufficiently intense to demonstrate effectiveness in changing violent, criminal, or drug use behavior following release. However, a few programs—Stay'n Out (in a New York prison), Cornerstone (in the Oregon State Hospital), and the California Civil Addict Program—combine elements of therapeutic communities in institutions with coordinated postrelease follow-up in the community. The IOM committee concluded from well-controlled prospective evaluations that, for inmates who complete them, these programs significantly reduce rearrest rates (Gerstein and Harwood, 1990:17). Community-Level Interventions Increasing Alcohol Excise Taxes A National Research Council study panel saw "good grounds for incorporating an interest in the prevention of alcohol problems into the setting of tax rates on alcohol" (Moore and Gerstein, 1981:114). An analysis by Cook (1981) for that panel found evidence suggesting that state-level rates of liquor consumption, and consequently auto fatalities and cirrhosis deaths, were reduced by increases in alcohol excise tax rates. We know of no similar analysis of how alcohol tax rates are related to violence rates. However, given the links between alcohol and violence, we believe that such an analysis should be carried out and its results considered in public debates about violence control policy. Moreover, changes in alcohol taxes and other control policies present opportunities to evaluate their effects on violence levels. Police Disruption of Illegal Drug Markets To disrupt active drug markets, police currently use three primary strategies alone or in combination: (1) targeted undercover operations to remove sellers or buyers from the scene; (2) highly visible sweeps or crackdowns, sometimes billed as "taking back the neighborhood"; and (3) cooperation with local community residents and organizations in antidrug efforts. Undercover tactics for street-level drug market disruption include the "buy- bust," in which the undercover officer buys illegal drugs and then (with assistance) arrests the seller, and the "reverse sting," in which the undercover officers pose as dealers, sell illegal drugs or an imitation, and arrest the buyer. In one evaluation, the use of undercover tactics in Birmingham, Alabama, may

ALCOHOL, OTHER PSYCHOACTIVE DRUGS, AND VIOLENCE 210 have produced a delayed decrease in violent crimes reported to the police. However, the effect is uncertain because the experimental controls broke down (Uchida et al., 1990). Drug-related police crackdowns are intended to achieve additional disruption through the high visibility associated with police saturation of a small target area. Crackdowns in Lynn and Lawrence, Massachusetts, New York City, Philadelphia, Oakland, California, and Washington, D.C., have been studied in some depth (Kleinman, 1986; Uchida et al., 1990). In the short run, these crackdowns reduced the volume of illegal drug sales on the streets in the targeted area. However, there is controversy over the extent to which the crackdowns merely moved the drug markets off the street into less visible locations in high- rise housing projects, displaced robberies and burglaries to surrounding areas, and accelerated a downward trend in the homicide rate that was occurring throughout the city at the same time. The evaluators of the Oakland effort made perhaps the only supportable generalization, that success in police crackdowns requires three interrelated elements: a highly committed police department, a receptive community, and a drug market that is not yet too firmly entrenched (Uchida et al., 1990). Currently, three comprehensive evaluations of how police activity affects drug trafficking and violent crime are under way in Pittsburgh, Kansas City, and Jersey City, under the National Institute of Justice Drug Market Analysis Program. With the aid of geocoding, the program will permit geographic analysis of police activity, drug marketing, and violent crime levels, so that both local and displacement effects can be observed. Police cooperation with the community in disrupting illegal drug markets includes meetings with community groups, interviews with citizens to inform them about early signs of developing drug markets and a telephone hotline for reporting suspicions, and distributions of leaflets about illegal psychoactive drugs and markets. This variety of community-oriented policing requires a major reorientation of police priorities that permeates through all ranks from the chief down to patrol officers. In one attempt to evaluate community cooperation as a drug market disruption tactic using a pretest/posttest design, the intervention was delivered in a disjointed and inconsistent way and failed to demonstrate any effects on robberies or violent crime, relative to a control beat (Uchida et al., 1990).

ALCOHOL, OTHER PSYCHOACTIVE DRUGS, AND VIOLENCE 211 RESEARCH AND EVALUATION NEEDS This chapter has discussed findings about a number of links between violence and psychoactive drugs including alcohol. While progress has been made in understanding those links and using them to reduce violence, much remains to be done. We consider the following areas to be most important in future research and evaluation programs: (1) developing medications to reduce drug craving and to reduce the aggression-promoting effects of alcohol use; (2) male-female differences in the link between alcohol use and violent behavior; (3) other individual differences—behavioral, genetic, and neurological —that distinguish people who behave violently while drinking alcohol from those who do not; (4) relating different combinations of multiple psychoactive drug use pharmacologically to aggressive and violent behavior in humans and other animals; (5) relating the various methods and patterns through which users commonly take psychoactive drugs to their patterns of violent behavior—in particular, ascertaining whether the rapid access of smoked "crack" cocaine to the brain produces perceptual distortions or violent behaviors that do not occur with powdered cocaine; (6) genetic processes that may influence the relationship between chronic alcohol abuse and aggressive or violent behavior in humans and other animals; (7) relationships between levels of violence related to illegal drug distribution and demographic and socioeconomic processes in the surrounding communities; (8) the incidence of violence that is indirectly related to alcohol or other drug use through incidents such as arguments over debt repayments, over the use of family money, and over time spent away from home; (9) profiles of the prevalence of alcohol and other psychoactive drug use by time of day and day of week, and by demographic and socioeconomic categories, as benchmarks for analyzing their causal role in violent events; and (10) evaluations using randomized experiments to test how the following approaches to reducing drug consumption affect violence levels: communityand school-based substance abuse prevention programs, urinalysis monitoring of drug-positive arrestees for violent offenses during pretrial release, substance abuse treatment

ALCOHOL, OTHER PSYCHOACTIVE DRUGS, AND VIOLENCE 212 for incarcerated drug-using violent offenders with coordinated postrelease follow-up in the community, and police disruption of illegal drug markets in cooperation with local community-based organizations. NOTES 1The urine specimens are tested for cocaine, opiates, marijuana, PCP, methadone, benzodiazepine (Valium), methaqualone, propoxyphene (Darvon), barbiturates, and amphetamines. Samples are collected at the time of arrest on a voluntary basis; an average of 80 percent of arrestees voluntarily cooperate. Test criteria are set to detect use of most drugs in the preceding 24 to 48 hours, but marijuana and PCP can be detected for several weeks after use. 2 Among studies of this relationship, many group all illegal drugs together. Those that distinguish among drugs usually list cocaine, heroin, amphetamines, barbiturates, and hallucinogens other than marijuana (Elliott and Huizinga, 1984). 3 Burglaries entail a risk of violence if the burglar encounters an occupant of the property. 4 Data from the experiment can be used to study how pretrial rearrest probability is related to positive test results because, according to Toborg et al. (1986), pretrial release was rarely revoked following a positive test result or even failure to show up for testing. References Adler, P.A. 1985 Wheeling and Dealing: An Ethnography of an Upper-Level Dealing and Smuggling Community. New York: Columbia University Press. Anderson, E. 1990 Streetwise: Race, Class, and Change in an Urban Community. Chicago: The University of Chicago Press. Anglin, M.D., and G. Speckart 1988 Narcotics use and crime: A multisample multimethod analysis. Criminology 26(2):197-233. Babor, T.F., S. Berglas, J.H. Mendelson, J. Ellingboe, and K. Miller 1983 Alcohol, affect, and the disinhibition of verbal behavior. Psychopharmacology 80:53-60. Ball, J.C., J.W. Schaeffer, and D.N. Nurco 1983 The day-to-day criminality of heroin addicts in Baltimore—A study in the continuity of offense rates. Drug and Alcohol Dependence 12:119-142. Blanchard, R.J., K. Hori, and D.C. Blanchard 1987 Ethanol effects on aggression of rats selected for different levels

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Understanding and Preventing Violence: Volume 1 Get This Book
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By conservative estimates, more than 16,000 violent crimes are committed or attempted every day in the United States. Violence involves many factors and spurs many viewpoints, and this diversity impedes our efforts to make the nation safer.

Now a landmark volume from the National Research Council presents the first comprehensive, readable synthesis of America's experience of violence--offering a fresh, interdisciplinary approach to understanding and preventing interpersonal violence and its consequences. Understanding and Preventing Violence provides the most complete, up-to-date responses available to these fundamental questions:

  • How much violence occurs in America?
  • How do different processes--biological, psychosocial, situational, and social--interact to determine violence levels?
  • What preventive strategies are suggested by our current knowledge of violence?
  • What are the most critical research needs?

Understanding and Preventing Violence explores the complexity of violent behavior in our society and puts forth a new framework for analyzing risk factors for violent events. From this framework the authors identify a number of "triggering" events, situational elements, and predisposing factors to violence--as well as many promising approaches to intervention.

Leading authorities explore such diverse but related topics as crime statistics; biological influences on violent behavior; the prison population explosion; developmental and public health perspectives on violence; violence in families; and the relationship between violence and race, ethnicity, poverty, guns, alcohol, and drugs.

Using four case studies, the volume reports on the role of evaluation in violence prevention policy. It also assesses current federal support for violence research and offers specific science policy recommendations.

This breakthrough book will be a key resource for policymakers in criminal and juvenile justice, law enforcement authorities, criminologists, psychologists, sociologists, public health professionals, researchers, faculty, students, and anyone interested in understanding and preventing violence.

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