Consequences of Addict Behavior in Society

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

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

Today more than 17 million people worldwide, including an estimated 1 million Americans, are infected with the human immunodeficiency virus (HIV) which causes AIDS. In the United States, according to the Centers for Disease Control and Prevention (CDC), AIDS is now the leading cause of death among 25- to 44-year-olds (Swan, 1995).

It now appears that injection drug use is the leading risk factor for new HIV infection in the United States (Holmberg, 1996). More than onethird of AIDS cases reported through December 1995 were related to injection of illicit drugs through three mechanisms: the sharing of contaminated injection equipment, heterosexual contact with an injection drug user (IDU), or through maternal injection of illicit drugs (Table 7.1) (CDC, 1995a). In women, the percentages of AIDS cases involving injection of illicit drugs are alarmingly high. Of the 71,818 female AIDS cases reported to CDC through December 1995, almost half (33,452 cases) were related to injection of illicit drugs and another 18 percent (13,046 cases) to sex with infected IDU partners (CDC, 1995a).

HIV can be transmitted through direct needle sharing when contaminated blood remains in the syringe and may be released into the next user or through certain injection drug practices during which blood is drawn into the syringe and mixed with the drug. Transmission of the virus can also occur indirectly by the sharing of drug injection equipment such as cotton balls or rinse water (NRC, 1995), and increased frequency of injection and the use of shared equipment increase the risk for seropositivity. HIV risk is also associated with the locations in which drug use occurs.

Injection drug use frequently occurs in ''shooting galleries" where users can rent a syringe and needle that is supplied from a common container. The injection equipment may or may not be rinsed, and if rinsed, may be rinsed with infected water.²

All drug users, injecting and noninjecting, place themselves at great risk for HIV transmission when engaging in unsafe sexual behavior while under the influence of drugs, such as alcohol and cocaine, or exchanging sex for money or drugs (Edlin et al., 1994; O'Connor et al., 1994). One study found that as many as 80 percent of male IDUs were in a primary

relationship with women who did not use drugs themselves (Des Jarlais et al., 1984). Since the beginning of the crack cocaine epidemic, that drug has been seen as a sexual stimulant, as well as the cause of high-risk sexual behavior in many users. The disinhibiting effect is stronger than that of depressants such as alcohol or heroin due to the rapid onset of the drug's "high" with a related rapid release of inhibitions (Fullilove and Fullilove, 1989; Chaisson et al., 1991; Edlin et al., 1994). Sex-for-drug exchanges and prostitution—associated with the need to acquire crack cocaine or the money to buy the drug—have resulted in the transmission of HIV to the non-drug-using populations (IOM, 1994).

Maternal-infant transmission of HIV is often an indirect health consequence of injection drug use. Of the 6,948 cases of AIDS in children under 13 years of age reported to CDC through December 1995, 90 percent are attributable to perinatal HIV transmission. Most (54 percent) of the pediatric AIDS cases are associated with injection of illicit drugs—37 percent with maternal injection of drugs and 17 percent with maternal sexual contact with an IDU (CDC, 1995a). Of all infants born to HIV-infected mothers who do not receive antiretroviral therapy (e.g., AZT), an estimated 15-35 percent of those infants become infected (Hardy, 1991; CDC, 1994, 1995b).

As the AIDS epidemic continues to spread, the financial burden of the disease on those affected, the health care system, and society in general will continue to grow. Because data on the use of and expenditures for medical services of persons with AIDS are scarce, the Agency for Health Care Policy and Research (AHCPR) established the AIDS Cost and Service Utilization Survey (ACSUS) in 1989. Estimates in 1992 forecast that the cumulative (national) costs of treating all HIV-infected individuals would surpass $15.2 billion in 1995 (see Table 7.2). That figure, which represents a 48 percent increase from the cost of $10.3 billion in 1992, reflects an increase in the average amount of services used by those infected with HIV as well as the availability of better data on the utilization of medical services (Hellinger, 1992; Oncology, 1993).

The United States funds 85 percent of the world's public sector investment in AIDS research, primarily through the National Institutes of Health (NIH) whose AIDS and AIDS-related research portfolio is currently a $1.4 billion effort (OAR, 1996). Research is aimed at all phases of the etiology, prevention, and treatment of the disease. The research accomplishments to date are numerous. This section highlights future research directions related to IDUs and AIDS research. Chapter 8 discusses further research opportunities in the treatment of HIV-infected drug abusers.

Measuring HIV prevalence (the number of infections at a point in time) and incidence (the number of new infections over time) is crucial to monitoring the course of the epidemic. Statistics on the incidence and prevalence of HIV infection provide a more complete assessment of the magnitude of the epidemic than end-stage statistics of AIDS cases. Efforts to determine HIV prevalence in the drug-abusing population have been based on a range of seroprevalence studies primarily of IDUs. The number of IDUs in the United States has been estimated to range from 1.1 million to 1.8 million (NRC, 1989; OTA, 1990). Estimates of HIV seroprevalence in the IDU population range from 0 to 50 percent depending largely on geographic location. In New York City, HIV seroprevalence was found to be slightly more than 50 percent in a study of injection drug users (Des Jarlais et al., 1994). The Centers for Disease Control and Prevention's HIV/AIDS Surveillance Report provides data on new HIV cases in IDUs. However, these data are not representative of all persons with HIV infection because some states also offer anonymous HIV testing, and the collection of demographic and risk information varies greatly among states (CDC, 1995a).

Because of the difficulties in locating and gaining access to the populations initiating or relapsing into injecting drugs, most of the epidemiological studies to date have focused on long-term, chronic IDUs (IOM, 1994). As a result, little is known about younger, new IDUs who may actually be at increased risk for HIV transmission due to engaging in higher levels of risk behaviors, including needle sharing and use of shooting galleries (Battjes et al., 1992). Additionally, little is known about the extent of HIV transmission that is due to sex-for-drug activities or drug-related prostitution.

Studies are needed to determine the prevalence of HIV infection among vulnerable populations of drug users. Information from such studies may help establish a basis for possible intervention programs directed at preventing further HIV transmission. More extensive epidemiological data regarding HIV incidence in the drug-using population are needed in order for AIDS treatment programs to accurately and adequately meet the needs of those infected.

Prevention and Risk Reduction Strategies

Although risk reduction strategies have primarily targeted current injection drug users, it is important for research to focus also on preventing initiation into intravenous drug use. A study by Battjes and colleagues (1992) found that early age of first injection is associated with higher levels of injection and sexual risk behaviors (including needle sharing, frequency of injection, use of shooting galleries, multiple sex partners, and prostitution).

Drug abuse can have a significant impact on the health of children who either are exposed to nicotine, alcohol, or illicit drugs prenatally through maternal drug abuse or grow up in a drug-abusing household. Although it is difficult to estimate the number of children in drug-abusing households, the National Pregnancy and Health Survey, sponsored by the National Institute of Drug Abuse (NIDA), provides nationwide estimates of the use of nicotine, alcohol, and illicit drugs by pregnant women. The survey estimated that in 1992, 20.4 percent of the women (an estimated 820,000 women) smoked cigarettes and 18.8 percent (757,000) used alcohol during pregnancy (NIDA, 1996). The survey also found that 5.5 percent of the women who gave birth (approximately 221,000 women out of 4 million nationally) used one or more illicit drugs during pregnancy; an estimated 119,000 women (2.9 percent) used marijuana, 45,000 (1.1 percent) used cocaine (34,800 of whom used crack cocaine), and 3,600 used heroin during pregnancy (NIDA, 1996).⁴

The economic costs of maternal drug use during pregnancy were estimated to exceed $500 million in 1990 for cocaine-exposed infants and $652 million annually for maternal cigarette smoking (Manning et al., 1989a,b; Phibbs et al., 1991; Frank et al., 1993). Prenatal exposure to these drugs may result in prematurity and low birth weight, which is one of the primary causes of extended hospital stays for drug-exposed infants. For example, a premature cocaine-exposed infant's hospital stay costs an average of $5,200 more than the cost of an unexposed infant (Phibbs et al., 1991). It is more difficult to estimate the cost of other health effects due to prenatal exposure (e.g., HIV infection⁵) or the collateral effects (e.g., homelessness, child abuse, neglect, and malnutrition) of growing up in a drug-abusing household.

The next section provides an overview of the known effects of nicotine, alcohol, heroin, marijuana, and cocaine on fetal development and on later behavior and developmental outcomes. It is followed by a discussion of opportunities for future research on prenatal exposure and on the effects of growing up in a drug-abusing household. Discussion is limited to nicotine, alcohol, heroin, marijuana, and cocaine because those drugs appear to be the most widely used during pregnancy, with the possible exception of caffeine. Before describing the accomplishments, however, the methodological difficulties associated with conducting research on prenatal exposure are discussed.

Nicotine, alcohol, heroin, marijuana, and cocaine readily cross the placenta and the blood-brain barrier, creating a potentially increased risk of adverse biological consequences to overall fetal development and specifically to fetal brain development. In most instances, however, demonstrating links between prenatal exposure and immediate or later outcomes is complicated by issues such as interactions with associated conditions

(e.g., poor nutrition, parental stress and psychiatric illness, sexually transmitted diseases) that may also impact on development (Frank et al., 1993; Finnegan, 1994). Further, the majority of women who use heroin, marijuana, or crack cocaine also use varying amounts of alcohol and/or nicotine and may use one or more illicit drugs in combination. Thus, rarely is it possible to speak, for example, of a "pure" crack cocaine effect.

Additionally, longitudinal studies of the developmental outcome of prenatal drug exposure in human infants face four methodological issues that cut across the specific agent of abuse and exposure (reviews by Jacobson and Jacobson, 1995; Neuspiel, 1995; Olson et al., 1995). First, there are difficulties in ascertaining the amount, frequency, and duration of drug abuse during pregnancy due to inaccuracies of maternal selfreport and limitations of current biological markers of exposure (Coles, 1992; Kidwell, 1992). Second, the high rate of attrition is a problem in studies of drug-abusing populations (Mayes and Cicchetti, 1995). Third, there are difficulties in choosing the appropriate comparison group (e.g., determining whether the comparison group is drug free or free only of the primary drug of interest, choosing appropriate demographic comparison cohorts). Fourth, determining the appropriate time (developmentally) and length of time to assess infants is another crucial issue. Traditional models of behavioral teratology presume effects that are present at least early in infancy but may or may not persist through childhood. Less frequently discussed are drug-related effects that are not apparent until later in development, when central nervous system processing of information or social skills are required, or during periods of major central nervous system reorganization (e.g, between age 4 and 5 years or during puberty) (see Weiss, 1995).

Animal models provide some basis for comparison because the amount of exposure and environmental conditions may be controlled. Animal models have been particularly useful for studies of the effects of prenatal exposures and for modeling drug-related effects on brain development at the structural, cellular, and functional levels. Neurobehavioral data from animal models should be viewed carefully, however, when extrapolating results from animal models to the complex developmental capacities found in higher primates and humans (e.g., language, complex problem-solving tasks, and neuropsychological functions such as certain domains of memory) (see Stanton and Spear, 1990).

Nicotine acts as a vasoconstrictor, reducing placental blood flow and the amount of oxygen and nutrients available to the fetus through several mechanisms. Additionally, smoking reduces the mother's appetite, and carbon monoxide from cigarette smoke crosses the placenta, increasing fetal carboxyhemoglobin levels (Werler et al., 1985). Those mechanisms are associated with retarding intrauterine growth in an apparent doseresponse relationship; the more cigarettes smoked, the lower is the birth weight (Zuckerman, 1991).⁶ Maternal cigarette smoking is also linked to higher rates of negative outcomes, including spontaneous abortions (Risch et al., 1988), stillbirths and perinatal death (Cnattingius et al., 1988; Malloy et al., 1988), and sudden infant death syndrome (SIDS) (Werler et al., 1985; Kandall and Gaines, 1991; Fried, 1992). Additionally, other toxins in cigarettes, including cadmium, lead, and thiocyanate, may also have adverse effects on the developing fetus (Kuhnert, 1991).

Prenatal Alcohol Exposure

that have not yet been elucidated (Schenker et al., 1990; Goodlett and West, 1992).

Studies of gestational ethanol exposure in nonhuman primates have explored dose-response relationships (e.g., Clarren et al., 1988, 1992). Fetal alcohol syndrome (FAS) is caused by prenatal exposure to high levels of alcohol and is characterized by intrauterine growth retardation with concomitant poor growth in fetal weight and/or height; a pattern of specific minor physical anomalies that include a characteristic facial appearance; and central nervous system deficits including microcephaly, delayed development, hyperactivity, attention deficits, intellectual delays, and learning disabilities (Clarren and Smith, 1978; Smith, 1982). Even in the absence of signs of FAS, infants born to alcoholic mothers show an increased incidence of intellectual impairment, congenital anomalies, and decreased birth weight (Sokol et al., 1980; Day, 1992; Aronson et al., 1985). Some children exposed prenatally to alcohol may show delayed development in their first two to three years (e.g., Jacobson et al., 1993; Day and Richardson, 1994) while others do not exhibit this tendency (Greene et al., 1990; Boyd et al., 1991).

Newborns who have been exposed prenatally to opiates (heroin or methadone), taken by the mother chronically during the pregnancy, are born passively dependent on the drug and may exhibit withdrawal symptoms in the first days to weeks after delivery (Desmond and Wilson, 1975). The withdrawal symptoms are characterized by hyperirritability, tremors, diarrhea, vomiting, and tachypnea (Finnegan, 1986). Prenatal opioid exposure increases the risk of reduced birth weight and head circumference (e.g., Zagon and McLaughlin, 1984; Doberczak et al., 1987) and of SIDS (e.g., Finnegan, 1979; Kandall et al., 1993). Similar findings in animal models that control for exposure to other drugs, such as alcohol and tobacco, and for poor maternal health support these findings on the effect of opiates on fetal growth (Zagon and McLaughlin, 1984).

Neurobehavioral assessments in the newborn period find that opiateexposed infants are more easily aroused, are more irritable, and have poor motor control (Strauss et al., 1976; Marcus and Hans, 1982; Jeremy and Hans, 1985). Such neurobehavioral abnormalities generally diminish over the first month of life (Jeremy and Hans, 1985) and thus are assumed to reflect the transitory symptoms of narcotic withdrawal rather than evidence of permanent neurological dysfunction (Hans, 1992).

Follow-up studies of opiate-exposed and non-opiate-exposed children have continued to report few to no differences in developmental and cognitive performance in comparison to social class-matched controls, although there is some indication of problems with motor coordination (Strauss et al., 1976). There are fewer studies of the long-term effects in school-age children of prenatal opiate exposure, and those available usually lack a nonexposed control group or are not based on a longitudinal design (Hans, 1992).

Prenatal Marijuana Exposure

Prenatal Cocaine Exposure

Research Opportunities

Windows of Biological Vulnerability

Effects of Multiple Drug Use

Self-Reports and Biological Markers of Exposure

Drug use and abuse are higher in men than in women, but there has been little research on the biological consequences to the fetus of paternal drug use or on the developmental effects of drug-abusing fathers as caregivers or as partners of drug-abusing mothers. Cocaine binds to human sperm in vitro, and studies have shown that extended use of cocaine increases the risk of lower sperm motility, lower sperm concentration, and higher proportion of morphologically abnormal sperm (Bracken et al., 1990; Yazigi et al., 1991). Thus, research is needed on the biological consequences, developmental outcomes, and psychological effects associated with parenting by a drug-abusing father.

Ongoing longitudinal research across geographic and sociodemographic ranges should be promoted to identify the health and developmental problems and delays caused by prenatal drug exposure or a drugabusing environment. As suggested earlier, the possibility of drug-related effects appearing either later in development or under stressful conditions later in life requires carefully maintained longitudinal cohorts. Studies to date have focused primarily on drug-abusing mothers in poor urban areas; the focus must be expanded to cover a wider geographic and socioeconomic range. Longitudinal studies also provide some modeling of the contribution of environmental disruption to the developmental course of apparent drug effects.

Studies of responsive caregiving in a stimulating social environment have shown the plasticity of neurobehavioral development and the potential that premature neonates have to catch up developmentally with full-term children (Beckwith and Parmalee, 1986; Kronstadt, 1991). Research is needed to study whether this plasticity is applicable to drugexposed infants because it will have important implications for preventive interventions and treatment efforts.

A major issue in neurotoxicology in general, as well as drug abuse research in particular, is how to measure noncognitive neurobehavioral outcomes (e.g., attention, affect regulation, social cognition) across the life span. Studies begun in the 1980s, during the height of crack cocaine use, are just beginning to yield longitudinal data. This type of long-term research is critical for providing public and private programs with necessary data on the needs for treatment and prevention services.

Effects of Parental Drug Abuse

Violence is a leading public concern in American society and is recognized as a major public health problem (Rosenberg and Fenley, 1991). The public health model—emphasizing prevention, research, and education— is being brought to bear on this devastating issue, and the CDC has made the prevention of violence one of its highest priorities (Rosenberg et al., 1992).

The complex and intertwined relationship between drug abuse and violence involves three primary links—systemic, economic, and pharmacological (Goldstein, 1985). It is noteworthy that different forms of violence are linked to different types of abused drugs. The systemic link, the most prevalent form of cocaine- and heroin-related violence, is the result of the violent nature of illicit drug selling and distribution (Goldstein, 1985; see Chapter 10). Illicit drug traffickers use violent acts or the threat of violence to protect and expand markets and to deal with competitors, buyers, or sellers suspected of cheating or with witnesses (BJS, 1992). A recent study of gun use found that it is predominantly sellers of illicit drugs, not users, who employ guns in their activities (Butterfield, 1995). Drug sales and crime are more strongly related than drug use and crime (Chaiken and Chaiken, 1990).

It is difficult to estimate the extent of systemic violence in the illicit drug trade. Police departments have reported that noticeable increases in violent crimes are associated with the sale and distribution of cocaine (Fagan and Chin, 1989). A 1987 study found that cocaine was involved in one-fifth of homicides in San Diego County (Bailey and Shaw, 1989). A 1993 National Research Council study estimated that crimes related to illicit drugs accounted for 10 percent of all homicides nationwide, more than 30 percent of homicides in certain cities, and more than 70 percent of homicides in high-risk areas of certain cities (NRC, 1993).

Income-generating crime is the indirect economic link between illicit drugs and violence. Drug-dependent individuals, particularly those dependent on heroin or cocaine, need substantial amounts of cash to support their drug habits, and some resort to robbery, motor vehicle theft, or other means of illegal and sometimes violently obtained income. In a 1991 survey of state prison inmates, 27 percent of those incarcerated for robbery reported committing the crime to obtain money to buy drugs (BJS, 1993). However, the majority of crimes committed by drug users are of a nonviolent nature (e.g., shoplifting, prostitution) (Goldstein, 1985).

Pharmacological Effects of Drugs and Violence

Alcohol

Opiates

Cocaine

Most studies of the pharmacological effects of lysergic acid diethylamide (LSD) and its relationship to violence were conducted in the 1960s and 1970s during the height of LSD use in the United States. Studies in humans show that LSD use is infrequently correlated with violence, but in cases where psychopathology predates LSD use, violent outbursts can be exacerbated (Miczek et al., 1994b).

Phencyclidine (PCP) use has been reported in some cases to be associated with violent behavior. However, it has been found that such individuals generally use PCP in conjunction with alcohol and other drugs (Miczek et al., 1994b). Animal studies have shown acute intake of PCP to be associated with inappropriate social signals, provocative actions, and hyperactivity which could be precursors of aggression (Tyler and Miczek, 1982; Schlemmer and Davis, 1983).

Marijuana users have been reported to have decreased aggression compared with nonusers (Cherek and Steinberg, 1987; Miczek et al., 1994b). Animal studies show that acute doses of THC, the psychoactive ingredient in marijuana, can inhibit attack or threat behavior (Miczek et al., 1994b). Large-scale studies of incarcerated adolescents found that marijuana was the drug least likely to be associated with sexual or assaultive crimes (Tinklenberg et al., 1976).

As noted, it is difficult to isolate the independent effect of the drug's pharmacology on an individual's violent behavior. Drugs may act as a cause, response, moderator, and/or mediator of violence (Fagan, 1993). Research is needed to determine the relationship between violence and the pharmacological effects of alcohol and illicit drugs in order to develop effective preventive interventions and treatment strategies, including research on patterns of alcohol and drug abuse involved in violent behavior and events in the early life history that are associated with violent behavior related to alcohol or drug abuse.

Although laboratory models should be developed to distinguish between the many confounding variables influencing the relationship between drug abuse and violence (Chapter 2), the difficulties inherent in replicating realistic conditions or precursory violence in the laboratory make this a formidable endeavor.

There is evidence of a complex linkage among violence, drug abuse, and co-occurring psychiatric disorders. As discussed in Chapter 4, illicit drug and alcohol abuse are significantly more prevalent among persons who suffer from psychiatric disorders (e.g., schizophrenia, bipolar disorder, and depression) than among persons without psychiatric disorders and are particularly common among those with personality disorders⁹ (Regier et al., 1990). Those individuals with co-occurring psychiatric disorders and drug abuse who are also at risk for violent behavior tend to manifest poor outcomes in standard treatment programs and often receive no treatment at all. Thus, they pose a special challenge to the treatment system, as well as to the criminal justice system (Drake and Wallach, 1989; Bartels et al., 1993; Drake et al., 1993; Narrow et al., 1993; Regier et al., 1993). It also has been found that personality disorders often precede the onset of drug abuse and other psychopathologies in persons who become violent criminals (Robins et al., 1991; Hien and Levin, 1994; Kessler and Magee, 1994; North et al., 1994; Widiger and Trull, 1994). Contextual factors-including race, gender, age, discrimination, poverty, homelessness, stressful life events, the characteristics of social networks, and the quality of living environments-are all likely to exert significant moderating effects on the relationships among victimization, co-occurring psychiatric disorders, and violent behavior (Pianta and Egeland, 1994; Hiday, 1995).

Studies have shown that the co-occurrence of psychiatric disorders with alcohol or drug abuse is associated with significantly increased risk for violent behavior in adults (Lindqvist and Allebeck, 1989; Swanson et al., 1990; Swanson, 1993; Mulvey, 1994). Although persons with co-occurring psychiatric disorders and drug abuse comprise only about 3.3 percent of the population (Regier et al., 1993), a recent study found that 7 percent of those diagnosed for depression (without a drug abuse diagnosis) had a history of violence, compared with 21 percent if comorbid for

drug abuse and depression (Monahan, 1995). Of those with bipolar disorder (without drug abuse), 5 percent had a history of violence, compared to more than 12 percent of those comorbid for drug abuse and bipolar disorder.

Some of the most important findings regarding the co-occurrence of psychiatric illness, drug abuse, and violence in the general population come from the Epidemiologic Catchment Area (ECA) surveys. This study of more than 20,000 community and institutional residents in five metropolitan areas found lifetime rates of drug abuse or dependence disorders to be as high as 47 percent among respondents with schizophrenia, 32 percent for those with major depressive illness, 56 percent for persons with bipolar affective disorder, and 87 percent for those with antisocial personality disorder (Regier et al., 1990). In data pooled from three ECA sites, about 2 percent of respondents with no disorder reported some violent behavior occurring within a one-year period. By comparison, the violence rates were 7 percent among those with a major psychiatric disorder only (schizophrenia or affective disorder) and 22 percent among those with co-occurring psychiatric and drug abuse disorders.

In multivariable models that controlled for age, sex, race, socioeconomic status, and marital status, the co-occurrence of psychiatric and drug abuse disorders emerged as one of the strongest predictors of violence toward others. Certain demographic covariates also increased the risk of violence among respondents with co-occurring disorders; among younger adult males of lower socioeconomic status, who reported a history of arrest and hospitalization, the predicted probability of violent acts within one year was 64 percent (Swanson, 1994).

Four mechanisms have been proposed to explain the underlying relationship between co-occurring drug abuse and psychiatric disorders and violence (Smith and Hucker, 1994). The first hypothesis is that violence in this group is linked primarily to the chemical effects of psychoactive drugs (e.g., cocaine may stimulate impulsive and aggressive behavior; alcohol may have a disinhibiting effect, possibly reducing tolerance for frustrating situations). Such effects may occur at lower doses for people with underlying psychiatric disorders (Drake et al., 1990). Antisocial personality traits often underlie both drug abuse and violence, and those antisocial traits may co-occur with psychotic disorders or other major psychiatric disorders as well. A third proposed mechanism is that drug use may exacerbate psychiatric symptoms, such as paranoid delusional beliefs, which can lead to violent actions in response to perceived threats. Finally, it has been proposed that social and economic factors—such as poverty and crime in the surrounding environment—largely account for the increased risk of violence among persons with co-occurring psychiatric and drug abuse disorders (Hiday, 1995). Limited evidence exists for each of those hypotheses individually; however, no studies to date have adequately assessed all of those factors together in an effort to examine their relative and interacting effects over time on interpersonal violence.

Although a sizable body of research has accumulated on selected aspects of violence, drug abuse, and co-occurring psychiatric disorders, key questions remain. They include the underlying mechanisms, developmental framework, and social context, as well as the long-term effectiveness of interventions that may be appropriate for this population. Thus, the committee urges a more comprehensive understanding of the risk factors associated with co-occurring psychiatric disorders and drug abuse and violence. Additionally, a more complete understanding of the types of interventions that may prove successful is needed.

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