The Opioid Crisis

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9Drugs, Alcohol, and Crime

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Learning Outcomes

After reading this chapter, you should be able to

• Discuss the relationship between substance use and criminal behavior.

• Recognize the criteria for substance use disorder according to the DSM-5.

• Examine several reasons why people use drugs.

• Explore the biological basis of addiction.

• List the types of commonly abused substances.

• Analyze the relationship between substance abuse and criminal behavior.

• Describe strategies for reducing substance abuse and substance-related crime.

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Introductory Case Study: Greg’s Alcohol Addiction

Introductory Case Study: Greg’s Alcohol Addiction Greg is a 47-year-old construction worker and divorced father of two high school–aged children (whom he rarely sees). Greg enjoys his job and has an exemplary work record; in fact, he was recently awarded Employee of the Month. Greg’s coworkers do not know a lot about him due to the fact that he is a private person and keeps to himself. But he joins them one or two nights a week for happy hour after work.

What Greg’s coworkers don’t know about him is that he had a rough childhood, which has led to him being very private and a loner. Greg’s parents were heavy drinkers while he was growing up, which led to Greg having very few friends and not performing well in school. Greg’s school troubles continued when he went to college, and he was not able to obtain a degree.

Greg found employment, married, and became a father, so it appeared that things were going well for him. Greg, though, has a secret—he is a heavy drinker himself. He enjoys going home after work and having a couple of beers, but a couple turned into 6 to 12 per night. This alcohol dependence eventually led his wife to seek a divorce.

Greg continued his alcohol dependence after his wife left him. He would become upset if there was not enough beer in the refrigerator, and he would go out and purchase more. In fact, one night he went out to purchase more and, when he got to the convenience store, realized he forgot his wallet. Instead of going home to retrieve his wallet, Greg chose to steal a six-pack of beer. He was caught attempting to leave the store without purchasing the beer. But the owner declined to press charges against Greg since he was a regular customer and the owner feared he might lose Greg’s business.

Greg started a dating a woman he met at a bar 18 months ago. She describes Greg as a warm and caring man but notes that he can act moody and cold toward other people on occasion. But she also states that she believes Greg suffers from some depression, due to not having a relation- ship with his children (which he will not discuss). She states that she has noticed throughout their relationship that Greg becomes restless and has trouble sleeping if he does not drink at least three or four beers after work. She states that she really cares for Greg and has considered asking him to slow down on his drinking or quit altogether but fears the repercussions of this request.

As you read this chapter, consider the following questions regarding this case:

1. Do you think Greg has an addiction to alcohol? 2. Are other people affected by his alcohol use? 3. Where did Greg get his opinions about drinking? 4. Do you think there is an underlying psychological disorder or genetic vulnerability

that is influencing Greg’s drinking? 5. Is Greg’s current attitude about alcohol use reasonable? 6. Do you think Greg is at risk for future criminal behavior?

167

Section 9.2 Substance Abuse and Addiction: Terminology and Diagnosis

9.1 Introduction There is a long-established link between substance (anything that can alter an individual’s cognition or mood) use and criminal behavior (Bradford, Greenberg, & Motayne, 1992; Tonry & Wilson, 1990). However, as we will explore in this chapter, it is important to note that there is no single substance use–crime relationship. In some instances, substance use precedes the criminal behavior. In other instances, the criminal behavior precedes the substance use. And sometimes both the substance use and the criminal behavior occur around the same time.

In addition, substances also differ in their criminogenic qualities (crime-causing potential). For example, a substance like marijuana is less criminogenic compared to a substance like heroin. However, in specific individual cases, and under certain situational conditions, mari- juana can be a highly criminogenic substance.

Substance abuse, in all its forms, impacts an enormous number of people, as well as their friends and families. Understanding the nature and extent of substance abuse allows us to make connections between substance abuse and criminal behavior.

9.2 Substance Abuse and Addiction: Terminology and Diagnosis Professionals and practitioners in a variety of fields—including psychology, criminal justice, health care, politics, and law—have tried to clarify terminology and concepts in an effort to improve public policy, professional standards, and patient care related to substance abuse (the hazardous or harmful use of substances) and addiction. As discussed in Chapter 2, in the field of psychology, the primary system that is used to diagnose mental disorders—including substance abuse and addiction—is the Diagnostic and Statistical Manual of Mental Disorders (DSM). In the DSM-5, which was published in 2013, the American Psychiatric Association rec- ommends that the term abuse be discontinued in favor of a more informative and less stigma- tizing term. However, the term substance abuse remains the most common term in use today, especially by state and federal governments as well as researchers in the field. We’ll refer to both abuse and use throughout this chapter, using the terms interchangeably.

The DSM-5 instead characterizes substance use disorders (patterns of symptoms resulting from the use of a substance that an individual continues to take despite experiencing prob- lems as a result of the substance use) as existing on a continuum from mild (two or three symptoms) to moderate (four or five symptoms) to severe (six or more symptoms). Each specific substance is addressed as a substance use disorder (e.g., alcohol use disorder, opioid use disorder), but nearly all are diagnosed based on the same overarching criteria.

Listed below are the criteria for substance use disorder according to the DSM-5.

1. Taking the substance in larger amounts or for longer than you’re meant to. 2. Wanting to cut down or stop using the substance but not managing to. 3. Spending a lot of time getting, using, or recovering from use of the substance. 4. Cravings and urges to use the substance.

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Section 9.3 Why Do People Use Drugs?

5. Not managing to do what you should at work, home, or school because of substance use.

6. Continuing to use, even when it causes problems in relationships. 7. Giving up important social, occupational, or recreational activities because of sub-

stance use. 8. Using substances again and again, even when it puts you in danger. 9. Continuing to use, even when you know you have a physical or psychological prob-

lem that could have been caused or made worse by the substance. 10. Needing more of the substance to get the effect you want (tolerance). 11. Development of withdrawal symptoms, which can be relieved by taking more of the

substance. (APA, 2013)

9.3 Why Do People Use Drugs? In general, any substance that alters the nervous system (network of nerve cells and fibers that transmit signals between different parts of the body; essentially, the body’s electrical wiring) and mind is con- sidered a drug. (Throughout the chapter, we’ll refer to the terms drug and substance interchangeably.) Certain drugs have the capacity to distort, inhibit, or enhance an individual’s thoughts or feelings, which impacts patterns of social functioning and other behaviors. Drugs are classified as either licit (legal) or illicit (illegal). For example, coffee, tobacco, and alcohol are considered licit drugs, as are popular over- the-counter drugs (e.g., Tylenol, Advil). When used infrequently or in moderation, these drugs are generally deemed acceptable by society. On the other hand, drugs like cocaine, heroin, and ecstasy are considered illicit drugs, which are illegal to use or possess in the United States.

In general, there are four primary reasons why people use drugs.

1. To feel good: Certain drugs can produce a feeling of well-being or elation, known as euphoria. This feeling of pleasure or euphoria can also be accompanied or followed by feelings of self-confidence, power, increased energy, satisfaction, or relaxation.

2. To feel better: Some individuals who suffer from depression, stress, or anxiety begin using certain drugs in an effort to eliminate or reduce those feelings. While people tend to dismiss the impact of stress, it has been found to play a strong role in indi- viduals starting and continuing substance use, as well as in relapse—a return to substance use after a period of improvement.

3. To perform better: Some individuals feel pressure to improve their performance in school, at work, or in a variety of other settings (e.g., athletics). Efforts to improve performance are a common reason that some people initially try or continue using stimulants, which will be described later in the chapter.

ookawaphoto/iStock/Getty Images Plus

When tobacco is used infrequently or in moderation, society generally considers its use acceptable. Tobacco is considered a licit drug.

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Section 9.4 Addiction

4. To conform to peer pressure and satisfy curiosity: These are common reasons for teenagers, as many teens become familiar with drugs and experience curiosity to try them. Social pressure from peers can also be a very powerful factor.

For many drugs, a user can be at risk of moving from occasional use to regular use. Similarly, a user can be at risk of moving from regular use to heavy use, and then from heavy use to chronic (constantly recurring or long-lasting) use. A chronic substance user may then be at risk of becoming addicted to the substance, as well as experiencing withdrawal symptoms (physical and mental symptoms that occur when a substance is absent from the body) when- ever the particular substance is not available.

9.4 Addiction Why do some people become addicted to certain substances while others do not? Why might someone feel sick from a certain drug that makes other people feel good? As with other mental health disorders, the likelihood of developing an addiction or substance abuse problem dif- fers from individual to individual. Moreover, there is no single factor that determines whether an individual will develop an addiction in the future.

People use the terms addiction and addict in everyday speech over a wide range of domains. For example, have you ever heard anyone refer to themselves as a shopaholic, chocoholic, or workaholic? Perhaps you have heard someone accuse themselves (or others) of having a television addiction or a social media addiction. Interestingly, the term addiction is included as a category in DSM-5 and contains both substance use disorders and non–substance use disorders, such as gambling disorder.

The American Society of Addiction Medicine published the following definition of addiction in 2011:

Addiction is a primary, chronic disease of brain reward, motivation, memory and related circuitry. Dysfunction in these circuits leads to characteristic bio- logical, psychological, social and spiritual manifestations. This is reflected in an individual pathologically pursuing reward and/or relief by substance use and other behaviors.

Addiction is characterized by inability to consistently abstain, impairment in behavioral control, craving, diminished recognition of significant problems with one’s behaviors and interpersonal relationships, and a dysfunctional emotional response. Like other chronic diseases, addiction often involves cycles of relapse and remission. Without treatment or engagement in recov- ery activities, addiction is progressive and can result in disability or prema- ture death. (paras. 1–2)

Addiction is a chronic disorder with environmental, biological, social, and psychological fac- tors that influence its development and maintenance.

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Section 9.4 Addiction

1. Environmental factors: Society’s views of substance use have a significant effect on people’s initial and continued use of certain substances.

2. Biological factors: The pharmacology of alcohol and other drug use centers on how the ingredients of a particular substance affect the body and nervous system and thus the individual’s experience with the substance.

3. Social factors: The motivation for using a particular substance can be influenced by a variety of social influences, including peer pressure, deviant peer relationships, social alienation, bullying, popularity, and association with gangs. The norms and expectations within families, communities, and subcultures are also strong social factors.

4. Psychological factors: Researchers have discovered consistent predictors of initial and continued substance use, including learning factors, personality variables, and higher order cognitive processes. Alcohol and other drug abuse is highly associated with affective disorders and other psychiatric diagnoses, although as noted earlier, some psychological problems (e.g., anxiety and depression) may be effects of the substance use as well as causal factors. (See Figure 9.1.) Many people who abuse substances have a history of low self-esteem, impulsivity, deviance, nonconformity, and antisocial behavior. However, these psychological factors can all be the effects (as opposed to the causes) of substance abuse.

Figure 9.1: Substance use disorder and mental illness among adults aged 18 or older: numbers in millions, 2017

Substance use disorder and addiction may cause mental disorders or other psychiatric diagnoses, but they also may be the effects of the mental disorders. This graph shows the overlap of mental illness and substance use disorder of adults in 2017.

From Key Substance Use and Mental Health Indicators in the United States: Results From the 2017 National Survey on Drug Use and Health (p. 41), by J. Bose, S. L. Hedden, R. N. Lipari, and E. Park-Lee, 2018, Rockville, MD: SAMHSA (https://www.samhsa.gov /data/report/2017-nsduh-annual-national-report).

8.5 million

38.1 million

Mental illness, no SUD

SUD, no mental

illness

SUD and mental illness

18.7 million adults had SUD

46.6 million adults had mental illness

10.2 million

Many people deem addiction to be an issue of personal weakness that originates out of self- gratification and continues because of an unwillingness or lack of sufficient willpower to stop. However, within the scientific and medical communities, the theory that addiction is driven solely by pleasure-seeking behavior has decreased in popularity. Instead, scientists and

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Section 9.4 Addiction

medical experts now believe that people engage in potentially addictive behaviors to escape emotional and/or physical discomfort. In other words, people commonly use alcohol or drugs to feel good (or feel better), as we learned in the previous section. Accordingly, the roots of addiction reside in behaviors associated with self-medicating and sensation seeking.

Emerging evidence suggests that addiction is functional. In other words, addictive behaviors serve while they also destroy. Addiction is a relationship between a person and an activity or an object. With addiction, the activity or object becomes increasingly more important, while previously important activities become increasingly less important. Ultimately, addiction is about the complex and common struggle between acting on impulse and resisting that impulse.

Genetics Numerous scientific advances have shaped our current interpretation of addiction. For exam- ple, genetic research has demonstrated that approximately half of the risk for addiction is biological or genetic, and that some people are predisposed to addiction but not to a specific type of addiction (Betz, Mihalic, Pinto, & Raffa, 2000; Blum et al., 2000; Potenza, 2001). Genes influence the degree of reward an individual experiences when initially using a substance (e.g., cocaine) or engaging in certain behaviors (e.g., gambling). In other words, it may be more difficult for some people with certain genes to quit using substances compared to other people. (See Case Study: Joanne.) In addition, some people may experience more severe with- drawal symptoms if they try to quit compared to other people.

Case Study: Joanne Joanne is a 51-year-old female who is in court-ordered treatment for depression and sub- stance use disorder. While she is not currently using drugs, she acknowledges that her use of cocaine and alcohol had spiraled out of control in the past year. Over the past several years, Joanne has been in and out of multiple jails and voluntary treatment programs, and she has become an expert in rationalizing her drug use.

Joanne had a very difficult upbringing. When she was 3 years old, her father committed sui- cide, and she was raised by a single mother who had a similar inability to control her drinking and drug use. Joanne was drinking and using drugs on a daily basis by the time she reached adolescence. By age 20 her drug use had moved from recreational to the dependent stages of addiction. Her cravings were so strong that she would skip any social or occupational activity to get drugs.

For the past year, Joanne has been secretly selling marijuana and antidepressant medication to several of her son’s classmates. She recognizes that her behavior is wrong, and this is one of many examples in which she is unable to use sound judgment.

Joanne’s recurrent drug use has resulted in a failure to fulfill major role obligations at work and at home. In fact, her most recent arrest stemmed from a DUI, which she received while driving to pick up her 14-year-old son from school. During treatment, Joanne learned that people with a first-degree relative (such as a parent) who has addiction problems are more likely to develop an addiction, and her greatest fear is that her son and 12-year-old daughter will inherit her problems with substance use.

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Section 9.4 Addiction

Genes also affect the way in which the body processes substances. An intensified desire to reexperience the use of a substance can lead to regular use and exposure, with chronic use and chronic exposure potentially leading to changes in brain chemistry. These changes may include negative impacts to impulse control, judgment, memory, and motivation. Moreover, these changes can lead to increases in cravings for a substance, as well as impairments in the ability to regulate the impulse, despite the experience and knowledge of the negative conse- quences associated with addiction.

The Brain and Addiction Most drugs associated with addiction affect the release of dopamine (a chemical in the brain that helps regulate emotional responses, learning, attention, and move- ment) in the brain’s reward system, which contains a set of neural pathways that are involved in the experience of pleasure. In addition, brain-imaging technologies have shown that our brains respond similarly to different pleasurable experiences, whether the pleasure is derived from ingesting alco- hol or other drugs or from engaging in behav- iors such as shopping, gambling, or exercise (Werme, Lindholm, Thoren, Franck, & Brene, 2002; Werme, Thoren, Olson, & Brene, 2000).

Syndrome Model of Addiction While most past research has focused on chemical objects of addiction, there is increasing evidence showing that behavioral objects of addiction (e.g., gambling, exercising) have a sim- ilar influence over the reward system. This indicates that seemingly disparate patterns of addiction, such as heroin addiction and sex addiction, might actually stem from a common cause. This emerging view among clinicians and addiction experts is known as the syndrome model of addiction (Shaffer et al., 2004), which supports the philosophy that there is only one addiction disorder, as opposed to many different addictions.

Furthermore, the syndrome model categorizes addiction as a complex condition with a vari- ety of symptoms and signs that are not always present for every person with the disorder. As a result, addiction gets expressed in many different ways, including a drug or drug-free activity (such as exercising, gambling, shopping, etc.). For addiction to develop, the activity or drug must shift a person’s subjective experience in a personally desirable direction.

These findings suggest that the specific behavior or substance of addiction is less important than previously thought.

©iStockphoto/Thinkstock

Brain-imaging technologies have shown that our brains respond similarly to different pleasurable experiences.

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Section 9.5 Major Types of Commonly Abused Substances

9.5 Major Types of Commonly Abused Substances Drugs of abuse can generally be described in four different categories: depressants, stimu- lants, opiates, and hallucinogens. From a biological standpoint, marijuana has depressant, stimulant, and hallucinogenic effects, and thus it will be considered separately.

Depressants Depressants reduce nervous system activity, resulting in reduced anxiety and an overall sense of relaxation. At higher doses, brain activity becomes more disrupted, and these sub- stances can produce stupor or insensibility. Motor skills and logical reasoning are affected, and fatigue may also result.

Alcohol is the most common depressant, and it is one of the most widely abused drugs in the United States. Moreover, alcohol abuse is the third leading preventable cause of death in the United States (CDC, 2014). Alcohol abuse is implicated in many homicides (for both the victim and perpetrator), automobile accidents, and hospital admissions. Excessive amounts of alcohol often cause blurred vision, loss of coordination, slurred speech, impaired motor skills, memory impairment, sudden mood swings, irregular pulse, vomiting, dizziness, and a progressive loss of inhibitions. One of the main effects on logical reasoning is the inability to think about possible outcomes of one’s actions, creating a short-sighted view of the world due to intoxication known as alcohol myopia. Long-term consequences of chronic heavy use may lead to ulcers, pancreatic damage, cirrhosis (liver failure), arrhythmia (irregular heartbeat), and high blood pressure.

Barbiturates—highly addictive drugs that act as a nervous system depressant—have been used historically as sleep aids and anxiety-reducing medications. Recently, they have been replaced in popularity by benzodiazepines, which are less prone to overdose. Benzodiazepine is a nervous system depressant that is often used to promote sleep and reduce anxiety; the most common benzodiazepine is diazepam (Valium). Similar to alcohol, both of these drugs can cause a sense of mild euphoria or relaxation. However, these drugs are highly addictive and can result in coma or death if taken with alcohol.

Stimulants Stimulants cause an increase in arousal in the nervous system. They increase blood pressure, pulse rate, alertness, euphoria, and excitation. Loss of appetite and insomnia are also common effects of stimulant use. Typically, the stimulant user experiences pleasant outcomes initially, such as a state of euphoria (“on a high”) with increased energy. It is also common for users to be talkative, feel restless, be hypervigilant (“on edge”), and have difficulty falling asleep.

Prolonged use of high doses of stimulants can result in brain damage or stroke and may produce significant personality changes. Other psychological effects associated with long- term stimulant use include anxiety, delusions of grandeur, confusion, paranoia, and violent behavior.

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Section 9.5 Major Types of Commonly Abused Substances

Major stimulants include cocaine, crack, amphetamine, methamphetamine, and ecstasy. Minor stimulants include sugar, caffeine, and nicotine, which are (in addition to alcohol) the most commonly used psychoactive substances in the United States. Moreover, some stimu- lants are considered to be gateway drugs that, while not necessarily addictive, may lead to the use of more or other addictive drugs.

Cocaine Cocaine is a highly addictive illegal stimulant drug of abuse that can be administered in one of four ways.

• Orally: Users may rub the drug onto their gums.

• Intravenously: Users may dissolve the drug in water and inject it.

• Intranasally: Users may snort the drug.

• Inhalation: Users may smoke the drug by inhaling its vapor into the lungs.

Cocaine use ranges from occasional to repeated or compulsive use. Any of the routes of administration listed previously can potentially lead to absorption of toxic amounts of the drug, causing strokes, sei- zures, respiratory failure, and heart attacks.

Crack is a form of cocaine that can be smoked, and it can be especially dangerous due to its fast and potent effects. It produces an immediate rush within 5 to 10 seconds of ingestion, and the high lasts only for a total of 5 to 15 minutes. This cycle of rapid “rush” and “crash” creates a cycle of craving the drug.

Amphetamines and Methamphetamines Amphetamines cause increased arousal, reduced appetite, and a decreased need for sleep. Physiological effects include an increase in blood pressure and heart rate, while psychologi- cal effects may include anxiety, hypervigilance, euphoria, and paranoia. Prolonged use of high doses of amphetamines can result in brain damage or stroke, and users commonly suffer from withdrawal after discontinuation, leading to irritability, depression, and fatigue.

Similarly, methamphetamines are highly addictive illegal stimulant drugs that are com- monly used to help people stay awake. Acute effects include loss of appetite, increasing heart

Brookhaven National Laboratory/Thinkstock

PET scans of a normal brain (top) and a cocaine abuser’s brain 10 days (middle) and 100 days (bottom) after using cocaine. Bright red and yellow indicates normal metabolic activity.

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Section 9.5 Major Types of Commonly Abused Substances

rate, difficulty breathing, irritability, hyperactivity, and insomnia. Long-term effects may include intense drug cravings and psychotic symptoms, including hostility, paranoia, or audi- tory hallucinations.

Ecstasy Ecstasy is a drug with both hallucinogenic (discussed later) and stimulant effects. Physiologi- cally, ecstasy causes increased blood pressure and heart rate, as well as nausea, chills, sweat- ing, teeth clenching, and blurry vision. Psychologically, ecstasy can cause feelings of increased alertness, euphoria, and an overwhelming sense of connectedness and well-being. While ecstasy commonly enhances sexual desire, it is also known to impair sexual performance.

Caffeine Believed to be the most popular drug in the world (it is consumed by approximately 90% of people), caffeine is a legal nervous system stimulant that occurs naturally in chocolate, tea, coffee, and other products. It is also artificially added to products like soda.

The effects of caffeine vary based on an individual’s sensitivity to the drug, and it does have addictive properties. When people who regularly consume caffeine stop abruptly, they can experience withdrawal symptoms like headaches, irritability, and fatigue. (Sugar has also been found to be an addictive substance with physiological and psychological effects similar to those of caffeine.) Fortunately, consumption of neither caffeine nor sugar has been found to be connected to criminal behavior.

Nicotine While nicotine—a potent stimulant that is found in tobacco—is highly addictive and con- sidered a gateway drug, its use has also not been found to be connected to criminal behavior. Nicotine use is often maintained because it helps reduce negative emotional states, including anger, fear, and anxiety; however, unlike certain other stimulants and substances discussed in this chapter, heavy use of nicotine has not been found to result in significant psychological disturbances.

Opiates and Opioids Opiates consist of naturally occurring, pain-reducing, and highly addictive drugs that are used in recreational and medical settings. Popular examples of opiates include morphine and codeine.

Opioids are similar to opiates, except opioids are the synthetic versions of these drugs. Heroin, hydrocodone, and oxycodone are among the most well-known opioids. These drugs depress the nervous system and produce a sense of euphoria and decreased reaction to pain. If taken in a high enough quantity, opioids can lead to stupor, insensibility, and possibly death by respiratory suppression. See Spotlight: The Opioid Crisis to learn about the problems that opioids—specifically prescription opioids—have caused in the United States.

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Section 9.5 Major Types of Commonly Abused Substances

Spotlight: The Opioid Crisis The United States has an opioid crisis. Nearly 130 Americans die every day from an overdose of opioids, the class of drugs that includes heroin, hydrocodone, oxycodone, morphine, and codeine. In 2017 more than 70,000 Americans died from drug overdose. In that same year, opioids killed more than 47,000 people, and 68% of those deaths involved prescription opioids. Deaths involving prescription opioids in 2017 were 6 times higher than in 1999 (CDC, 2018).

It is estimated that prescription opioid abuse in the United States costs $78.5 billion a year, including health care and addiction treatment costs, lost productivity, and law enforcement involvement (Florence, Feijun, Xu, & Zhou, 2016). Drug overdose is now the leading cause of accidental death in the United States, and opioid addiction is driving this crisis. (See Figure 9.2.)

So, what can be done? Reducing the number of deaths connected to opioid use will require addressing the issue from multiple angles. For example, in many treatment facilities, clinicians are attempting to reduce or eliminate patients’ exposure to opioid pain medications.

(continued)

Figure 9.2: U.S. opioid overdose deaths over past 20 years

Opioid overdose deaths continue to increase in the United States. From 1999 to 2017, nearly 400,000 people died from an overdose involving an opioid.

From “Understanding the Epidemic,” by the Centers for Disease Control and Prevention, 2018 (https://www.cdc .gov/drugoverdose/epidemic/index.html).

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Wave 1: Rise in prescription opioid overdose deaths

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deaths

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Section 9.5 Major Types of Commonly Abused Substances

Hallucinogens Hallucinogens frequently cause enhancement of sensory experiences and distortions of real- ity. In other words, these drugs produce a very intense alteration of feelings, thoughts, and perceptions. Physiological effects include sweating, dilation of pupils, and increased blood pressure, body temperature, and heart rate. Tolerance to hallucinogens builds rapidly, which means that people need to take steadily increasing amounts of these drugs to experience similar effects. LSD and ecstasy are among the most common hallucinogens.

Interestingly, most research indicates that use of hallucinogens does not increase criminal or violent behavior, although people’s emotional responses can vary greatly. For example, for some people use of hallucinogens can increase the effects of preexisting psychopathology, including aggression or violent behavior.

Marijuana Marijuana is the most widely used illicit drug, although an increasing number of states are moving (or have already moved) toward legalizing the drug. The pros and cons of this movement continue to be debated, particularly from public health, social justice, and law enforcement per- spectives. In addition, there are still many unanswered questions about the economic impact of legalization.

What does science tell us about the risks and benefits of marijuana use? Marijua- na’s popularity is tied to its mood-altering effects. Specifically, marijuana produces an altered state of consciousness characterized by relaxation and euphoria. It also produces

Spotlight: The Opioid Crisis (continued) Additionally, there has been a dramatic rise in community-based education efforts. These ini- tiatives are typically aimed toward educating people about opioids while helping reduce the stigma associated with seeking treatment and resources for opioid use disorder.

Community-based education has also assisted local leaders and decision makers in utilizing resources and building capacity for multifaceted community conversations and policy actions related to opioid use.

Finally, several states are working to introduce legislation to expand rehabilitation and inter- vention services for those impacted by the growing opioid crisis. For example, in the state of Florida, legislation passed in 2019 restricts opioid prescriptions to no more than a 3-day sup- ply (Regulation of Professions and Occupations, 2019).

Seth Michael/iStock/Getty Images Plus

A marijuana farmer examines his plants. A number of states—including Washington, Oregon, California, Nevada, Colorado, Michigan, Alaska, Maine, Massachusetts, and Vermont—and the District of Columbia have fully legalized the drug.

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Section 9.6 Relationship Between Substance Abuse and Criminal Behavior

physiological effects, including fatigue, lowered blood pressure, and increased appetite, as well as perceptual alterations such as impairments to reaction time, motor skills, and short- term memory. In addition, there is a significant linkage between heavy marijuana use and criminal involvement.

9.6 Relationship Between Substance Abuse and Criminal Behavior Research consistently demonstrates a strong connection between substance abuse and crimi- nal behavior. Most people entering the criminal justice system have substance use problems and/or are using illicit substances at the time of their arrest (Belenko & Peugh, 2005; Chan- dler, Fletcher, & Volkow, 2009). In addition, many individuals engage in criminal behavior to get money to purchase drugs, and the sale of drugs is often likely to take place in situations in which other crimes may occur. And stimulants such as methamphetamines have psychologi- cal and physiological effects that can increase the likelihood of engaging in criminal behavior (Cartier, Farabee, & Prendergast, 2006).

Table 9.1 provides statistics on how many state and local prisoners are reported to have used drugs during a crime and a month before a crime. Drug use in the month before and at the time of property and drug offenses among sentenced jail inmates was slightly higher than for state prisoners. A third to half of all state and local prisoners had used drugs during or soon before committing the crimes for which they were arrested.

Table 9.1: Drug use among state prisoners and sentenced jail inmates, 2007–2009

State prisoners Sentenced jail inmates

Characteristic Month before

offense At time of

offense Month before

offense At time of

offense

All inmates 39.3% 42.0% 54.5% 37.2%

Most serious offense

Violent 34.4% 39.9% 53.6% 37.2%

Property 47.0% 50.1% 63.4% 46.4%

Drug 47.1% 50.2% 66.6% 50.6%

DWI/DUI 33.5% 27.5% 24.2% 16.8%

Source: From Drug Use, Dependence, and Abuse Among State Prisoners and Jail Inmates, 2007–2009 (p. 6), by J. Bronson, J. Stroop, S. Zimmer, and M. Berzofsky, 2017. Washington, DC: Bureau of Justice Statistics.

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Section 9.6 Relationship Between Substance Abuse and Criminal Behavior

While it’s not feasible to summarize the entire body of research, there have been two note- worthy meta-analyses (systemic reviews on the literature) and several research studies with particularly interesting results.

Noteworthy Reviews and Studies Derzon and Lipsey (1999) conducted a review and an analysis of existing evaluation stud- ies that examined the relationship between marijuana use and problem behaviors, including juvenile delinquency (i.e., behavior by a young person that is illegal or wrongful; discussed in Chapter 6). Their review was based on 63 reports that summarized 30 independent studies and found a significant association between marijuana use and various forms of delinquency, including property crimes, aggressive behavior, and crimes against a person.

In a subsequent review, Bennett, Holloway, and Farrington (2008) examined the results of 30 studies that presented findings on the relationship between measures of substance use and measures of crime. The results showed that the likelihood of engaging in criminal behav- ior was approximately 3 to 4 times greater for substance users than non-substance users. In addition, the researchers discovered that the relationship between substance use and crime varied widely depending on the substance that was used. For example, crack cocaine use displayed the strongest relationship with criminal behavior, followed by heroin and powder cocaine. Recreational substance use was also found to be connected with criminal behavior, but at a much lower level than frequent use. In addition, marijuana users were found to be 1.46 times more likely to commit crimes compared to non-marijuana users, and amphetamine users were 1.93 times more likely to engage in crime compared to non-amphetamine users.

In addition to these meta-analyses, three distinct types of research have also helped establish the relationship between substance use and criminal behavior: general surveys of substance use, studies of criminal behavior in substance-abusing populations, and studies on substance abuse in criminal populations.

General Surveys of Substance Use As an example of a general survey, the CDC’s 2017 Youth Risk Behavior Surveillance consisted of a nationally representative sample of thousands of students enrolled in private and public high school students throughout the United States. According to this survey, 5.5% indicated that they had driven a car under the influence of alcohol, and 13% indicated that they had driven a car under the influence of marijuana. In addition, compared to other students, more than 2 times as many students who reported significant substance use also indicated that they carried a weapon or had gotten into a fight in the past 30 days. Take a look at Tables 9.2 and 9.3 for a breakdown of the statistics for males and females according to race and grade level.

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Section 9.6 Relationship Between Substance Abuse and Criminal Behavior

Table 9.2: Percentage of high school students who drove after drinking alcohol*

Category Female Male Total

Race/Ethnicity

White 3.8 6.3 5.0

Black 4.2 4.1 4.1

Hispanic 5.4 8.5 7.0

Grade

9 2.4 4.0 3.2

10 2.4 4.9 3.2

11 4.1 6.9 5.5

12 5.9 10.4 8.1

*In a car or other vehicle, one or more times during the 30 days before the survey, among the 62.6% of students nationwide who had driven a car or other vehicle during the 30 days before the survey.

Source: From “Youth Risk Behavior Surveillance—United States, 2017,” by the Centers for Disease Control and Prevention, 2018, Surveillance Summaries, 67.

Table 9.3: Percentage of high school students who drove after using marijuana*

Category Female Male Total

Race/Ethnicity

White 10.2 13.7 11.9

Black 13.3 14.1 13.7

Hispanic 13.6 15.9 14.8

Grade

9 4.5 10.2 7.3

10 8.9 13.5 11.3

11 11.7 12.8 12.3

12 16.5 20.1 18.3

*In a car or other vehicle, one or more times during the 30 days before the survey, among the 62.6% of students nationwide who had driven a car or other vehicle during the 30 days before the survey.

Source: From “Youth Risk Behavior Surveillance—United States, 2017,” by the Centers for Disease Control and Prevention, 2018, Surveillance Summaries, 67.

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Section 9.6 Relationship Between Substance Abuse and Criminal Behavior

Studies of Criminal Behavior in Substance-Abusing Populations There is a vast amount of research regarding criminal behavior in substance-abusing popula- tions. For example, a study involving more than 200 heroin users determined that more than 95% of those heroin users were engaged in other illegal activities (Johnson, Maher, & Fried- man, 2001). A separate study determined that approximately 99% of those heroin users had committed at least one crime in the past year (Inciardi, 1986). While the majority of crimes included drug sales and property offenses, thousands of burglaries, robberies, and assaults also occurred. Additionally, a study focused on opiate abusers reported that nearly 95% of heroin users were engaged in other criminal behaviors and that their participation in crimes was highest during their periods of heaviest heroin abuse (Nurco, Hanlon, Kinlock, & Slaght, 1989).

As you can see, there is a significant amount of research that has investigated the relation- ships between criminal behaviors and types of substance use. This is true both in the United States and internationally. In an Australian study, Makkai (2001) found that arrestees testing positive for opiate use were more than 4 times as likely to be charged with a property offense compared to arrestees who were non-opiate users. Additionally, arrestees who tested posi- tive for cocaine use were more than 2 times as likely to be charged with a violent offense.

In a study conducted in the United States, Johnson, Natarajan, Dunlap, and Elmoghazy (1994) conducted interviews with more than 1,000 substance abusers and found differences between the abuser types. For example, crack users were found to be more likely than non-substance abusers to report shoplifting offenses (21% compared to 9%). In a separate study, Johnston, O’Malley, and Eveland (1978) found a strong relationship between substance abuse and dif- ferent types of criminal behavior, includ- ing interpersonal violence. Specifically, the drugs that were most strongly correlated with interpersonal violence were cocaine, heroin, amphetamines, and barbiturates.

More recently, Bennett and Holloway (2005) found that users of cocaine and heroin were nearly 5 times more likely to commit shoplifting offenses than nonusers. Also, marijuana users were nearly twice as likely to commit nonresidential burglar- ies compared to non-marijuana users and approximately 3 times as likely to commit drug-supply offenses.

Studies on Substance Abuse in Criminal Populations Studies on substance abuse with incarcerated offender populations have also yielded infor- mative results. For example, Karberg and James (2005) surveyed more than 600,000 prison- ers and found that 68% of them met criteria for substance abuse. The results of this study also indicated that more extensive substance use by prisoners was correlated with a more exten- sive history of criminal behavior. In addition, the Arrestee Drug Abuse Monitoring Program was an excellent resource in establishing the prevalence of substance use among arrestees.

vchal/iStock/Getty Images Plus

Bennett and Holloway (2005) found that users of cocaine and heroin were nearly 5 times more likely to commit shoplifting offenses.

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Section 9.6 Relationship Between Substance Abuse and Criminal Behavior

In 2001 the research program identified several key findings related to substance use and criminal behavior, including the following.

1. Urine tests of people arrested indicated that 65% tested positive for at least one illegal substance.

2. Cocaine or opiate use was found in 29% of people arrested. 3. Repeat offenders accounted for 15% of those arrested; they indicated regular use of

crack or heroin. 4. Users of crack and heroin represented less than 25% of the sample yet were respon-

sible for more than 60% of the illegal income reported. 5. Of those arrested, 40% acknowledged a relationship between their own substance

use and criminal behavior. (National Institute of Justice, 2006)

Research conducted on substance abuse in both criminal populations and their victims sup- ports a strong relationship between criminal behavior and substance abuse. For example, the National Crime Victimization Survey presents national data on an annual basis about crimi- nal victimization in the United States. One of the questions asked on this survey to victims is whether they believed the perpetrator was under the influence of alcohol or drugs at the time of the crime. Consistently, victims have indicated that approximately 50% of the perpetrators appeared to be under the influence at the time of the crime (Bureau of Justice Statistics, 2018).

The results of research in this area are highly consistent in determining that people who com- mit crimes are far more likely to abuse substances than people who do not commit crimes.

Consequences of Criminal Behavior Related to Substance Abuse The use of illicit substances exposes people to criminal prosecution by local, state, and fed- eral authorities. Immediate penalties can include fines, loss of driving privileges, and possible time in prison. Moreover, people who abuse substances in early adulthood may establish pat- terns of behavior that later disrupt their careers and limit their ability to maintain healthy family and social lives.

Substance abuse undoubtedly constitutes a major problem in the United States and around the world. Substance abuse can lead to a variety of negative outcomes, including a long- lasting decrease in occupational and social functioning, as well as rates of greater morbidity and early mortality. Out of every 100,000 people around the world, 33 are estimated to die from alcohol-related causes, and 7 are estimated to die from illegal drug use (Peacock et al., 2018). The Bureau of Justice Statistics (2018) reports that 3.9% of the 14,831 homicides that were committed in 2007 were substance related. From 2000 to 2010, the CDC (2012) reported a 55% increase in heroin-related deaths.

Overall, the consequences of criminal behavior related to substance abuse are astounding. The emotional costs to individuals with substance use disorders, their families, and the vic- tims of their crimes are incalculable. In addition, substance abuse involves great financial costs for societies, including direct and indirect costs associated with criminal activity, law enforcement, accidents, hospitalization, and treatment. The National Institute on Drug Abuse (NIDA, 2017) estimates that the total crime-, work-, and health care–related costs of sub- stance abuse were more than $740 billion annually.

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Section 9.7 Strategies for Reducing Substance Abuse and Substance-Related Crime

9.7 Strategies for Reducing Substance Abuse and Substance-Related Crime Substance use disorders are among the most preventable health issues in the United States. Strong empirical evidence over the past several decades has consistently demonstrated that substance abuse treatment reduces criminal behavior. Treatment might include individual counseling and/or family-based treatment. For some people in need of alcohol or other drug treatment, contact with the criminal justice system can sometimes represent their first oppor- tunity for treatment. Moreover, legal incentives (e.g., consequences) may motivate someone to get treatment who was otherwise resistant.

For other people, getting arrested or incarcerated is part of a recurring cycle of substance abuse and criminal behavior. People with ingrained patterns of maladaptive beliefs and cop- ing skills may require a more intensive treatment approach, particularly among people with a prolonged history of substance abuse and criminal behavior. Illicit substance abuse also increases the likelihood of continued involvement in crime, with high rates of relapse and criminal recidivism among offenders. In fact, research has shown that 68% of substance- related offenders are rearrested within 3 years of release from jail (Levin, 2006). Fortunately, there are effective treatment models for prisoners and, in addition to beneficial effects for public health and safety, substance abuse treatment has been shown to improve outcomes for substance-abusing offenders.

The NIDA (2014) has been a key supporter of research on substance abuse treatment for individuals involved in the criminal justice system, and findings have shown that providing comprehensive substance abuse treatment is effective in reducing both substance abuse and recidivism. Moreover, based on a comprehensive review of the research literature, as well as consensus from experts in substance abuse research and practice, the NIDA has developed a monograph summarizing several key principles for effective treatment. Specifically, the NIDA recommends the following.

1. Treatment must be long enough to produce stable behavioral changes. 2. Services should be tailored to fit the needs of the individual. 3. Treatment should be carefully monitored. 4. Continuity of care is critical as criminals make the transition back into the community.

Supply, Demand, and Harm Reduction Treatment Model Additionally, the U.S. government has developed several important strategies for reducing substance abuse, including supply reduction, demand reduction, and harm reduction. The most effective way of tackling the substance abuse problem and crime problems in the United States involves a comprehensive, coordinated, and balanced approach, in which supply reduc- tion, demand reduction, and harm reduction all reinforce each other.

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Section 9.7 Strategies for Reducing Substance Abuse and Substance-Related Crime

The supply reduction approach attempts to put actions and policies in place that are designed to reduce the production and supply of illicit substances. One example of an effective supply reduction policy is interdiction, which involves intercepting or destroying supplies of illicit substances across U.S. borders.

The demand reduction strategy involves minimizing the actual demand for illicit substances. A prominent example of the demand reduction approach is educational youth programs that are designed to rein- force attitudes, behaviors, skills, and values associated with resisting substance use.

Finally, harm reduction is a set of ideas and public health strategies aimed at reducing nega- tive consequences associated with substance abuse. Philosophically, harm reduction accepts that a continuing level of substance use (both legal and illegal) in society is inevitable. Thus, its objectives are reducing negative economic, social, and health outcomes. An example of harm reduction is to provide individuals with information aimed at reducing the harmful consequences of the behavior when it occurs.

Biopsychosocial Model of Treatment In terms of treatment, the most successful substance abuse and addiction treatment programs utilize strategies to manage triggers, reduce cravings, enhance coping, and prevent relapse. Recovery requires an approach that systematically considers the biological, psychological, and social aspects of substance abuse. In psychology, this is referred to as the biopsychosocial model of treatment.

Consider the following example. One of the coauthors of this textbook had a colleague who once suffered a workplace injury that required long-term pain management. This colleague had a social circle of friends that encouraged the use (and abuse) of alcohol and opiates, which ultimately resulted in a life-changing drug addiction.

The most effective treatment for this individual would be one that explores the biopsychoso- cial factors involved in the abuse of and ultimate addiction to alcohol and opiates. As noted in Figure 9.3, some of these factors may have been financial stress, a negative life event (work- place accident), age, and poor social support.

mofles/iStock/Getty Images Plus

Interdiction involves intercepting or destroying supplies of illicit substances across U.S. borders.

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Summary and Conclusion

Summary and Conclusion

The relationship between substance abuse and crime is complex. There are four primary reasons why people use drugs and other substances: to feel good, to feel better, to perform better, and to conform to peer pressure or satisfy curiosity. There is always a risk that an individual may move from regular to chronic substance abuse and develop an addiction.

Substance use and addiction are influenced by broad cultural, economic, environmental, social, and situational contexts that influence the likelihood of crime occurring. While the exact mechanisms underlying addiction are not fully understood, it is hypothesized that the contribution of differing factors (biological, psychological, social) varies between indi- viduals. The current classification system that is primarily used to diagnose addiction and substance use disorders is the DSM.

Figure 9.3: Biopsychosocial model of health

The biopsychosocial model considers biological, psychological, and social factors and their complex interactions in understanding substance use and abuse.

Engle’s biopsychosocial model of health and disease adapted for our study by Tesfa Dejenie Habtewold, used under CC BY / Adapted from original.

Health

Biological factors: Age, sex, comorbid disease,

genetics, physical health, personality/temperament

Social factors: Socioeconomic status,

educational status, marital status, major family conflict, poor

social support

Psychological factors: Unemployment, financial stress,

negative life event, pill burden, smoking,

lack of regular physical exercise

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Summary and Conclusion

This chapter also provided a brief overview of the major types of commonly abused substances—depressants, stimulants, opiates and opioids, hallucinogens, and marijuana— and their links to criminal behavior. Alcohol and drugs are commonly found in both offend- ers and victims of crimes. Substance abuse is highly associated with criminal behavior; there is strong evidence that substance abusers are more likely than non-substance abusers to engage in criminal behavior and that people who commit crimes are more likely to be sub- stance abusers than people who do not commit crimes.

Major strategies for reducing substance abuse and substance-related crime include supply reduction, demand reduction, and harm reduction. Supply reduction involves implementing policies that are designed to reduce the production and supply of illicit substances. Demand reduction involves reducing the actual demand for illicit substances, primarily by working with youth and teaching them to resist drug use. Harm reduction aims to reduce negative economic, health, and social consequences associated with substance abuse.

Critical Thinking Questions

1. If a person abuses an illicit substance, should she or he be treated as a criminal? Or should the person be treated as someone who has a disease?

2. Is the relationship between substance use and mental illness important when think- ing about crime? Why or why not?

3. Do you think parents should be prosecuted when their children (under the age of 18) abuse illicit substances? Why or why not?

Key Terms addiction A chronic disorder with environmental, biological, social, and psychological factors that influence its development and maintenance.

alcohol myopia The inability to think about possible consequences of one’s actions due to alcohol intoxication.

amphetamine A nervous system stimulant that causes physiological effects such as increased arousal, a reduction in appetite, a decreased need for sleep, and psychological effects such as anxiety, euphoria, and paranoia.

barbiturate A highly addictive drug that acts as a nervous system depressant and is often used for insomnia and anxiety.

benzodiazepine A nervous system depressant that is often used to promote sleep and reduce anxiety.

caffeine A legal nervous system stimulant naturally occurring in chocolate, tea, coffee, and other products.

chronic Constantly recurring or persisting for a long time.

cocaine An addictive stimulant drug that increases arousal in the nervous system and results in a euphoric high.

crack A powder form of cocaine that can be smoked. Produces an immediate “rush” within 5 to 10 seconds of ingestion and a subsequent “crash.”

demand reduction A drug reduction policy that involves actions and strategies designed to decrease or eliminate an individual’s desire to use illicit substances.

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Summary and Conclusion

depressant Any substance that reduces functioning of the nervous system. Produces reduced anxiety and an overall sense of relaxation.

dopamine A chemical in the brain that helps regulate emotional responses, learning, attention, and movement.

drug Any substance that alters the functioning of the nervous system and mind.

ecstasy An illegal drug with stimulant and hallucinogenic effects.

euphoria A feeling of well-being or elation.

gateway drugs Habit-forming drugs that, while not necessarily addictive, may lead to the use of more or other addictive drugs.

hallucinogens A diverse group of drugs that alter feelings, thoughts, and perceptions.

harm reduction A set of ideas and strategies aimed at reducing negative consequences associated with substance use.

interdiction An effective supply reduction policy that involves intercepting or destroying supplies of prohibited items.

marijuana A drug that produces mood- altering effects such as relaxation and euphoria. Though illegal in some states, an increasing number of states are moving toward legalizing it for recreational or medical use.

methamphetamine A highly addictive and potent nervous system stimulant commonly used to help people stay awake.

nervous system The network of nerve cells and fibers that transmit signals between different parts of the body. Essentially the body’s wiring.

nicotine A potent stimulant that is found in tobacco.

opiates Naturally occurring, pain- reducing, and highly addictive drugs used in recreational and medical settings.

opioids The synthetic versions of opiates.

relapse A return to substance use after a period of improvement.

reward system The set of neural pathways in the brain that are involved in the experience of pleasure.

stimulant A drug that causes an increase in arousal of the nervous system. These include cocaine, amphetamines, methamphetamines, ecstasy, caffeine, and nicotine.

substance Anything that can alter an individual’s cognition or mood.

substance abuse The hazardous or harmful use of substances. This term is no longer included in the DSM-5; however, it is still commonly used by researchers and government officials.

substance use disorders Patterns of symptoms resulting from the use of a substance that an individual continues to take despite experiencing problems as a result of the substance use. This is the current terminology used in the DSM-5.

supply reduction A drug reduction policy that involves actions and strategies designed to reduce the production and supply of illicit substances.

syndrome model of addiction A theory that suggests there is one addiction that is associated with multiple expressions.

withdrawal symptoms Physical and/or psychological symptoms that occur when a substance is absent from the body.