165

9Drugs, Alcohol, and Crime

gorodenkoff/iStock/Getty Images Plus

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.

© 2020 Zovio, Inc. All rights reserved. Not for resale or redistribution.

166

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?

© 2020 Zovio, Inc. All rights reserved. Not for resale or redistribution.

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.

© 2020 Zovio, Inc. All rights reserved. Not for resale or redistribution.

168

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.

© 2020 Zovio, Inc. All rights reserved. Not for resale or redistribution.

169

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.

© 2020 Zovio, Inc. All rights reserved. Not for resale or redistribution.

170

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

© 2020 Zovio, Inc. All rights reserved. Not for resale or redistribution.

171

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.

© 2020 Zovio, Inc. All rights reserved. Not for resale or redistribution.

172

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.

© 2020 Zovio, Inc. All rights reserved. Not for resale or redistribution.

173

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.

© 2020 Zovio, Inc. All rights reserved. Not for resale or redistribution.

174

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.

© 2020 Zovio, Inc. All rights reserved. Not for resale or redistribution.

175

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 regul