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Page 182 4 Alcohol, Other Psychoactive Drugs, and Violence The connections between violence and alcohol and other psychoactive drugsprimarily opiates, cocaine, amphetamines, PCP, and hallucinogenshave rarely received much weight in developing national policy. Historically, mercantilist national ambitions, tariff revenue, presumed medical properties, the ethnic and social status of users, and moral assessments of alcohol and other drug use have played more prominent roles in formulating drug policy (Musto, 1973). Even today, despite anecdotal and research support for some connections between illegal drugs and violence, and despite reports of recent dramatic increases in drug-related violent deaths, violence remains a secondary consideration in formulating federal drug policy (White House, 1990). Whether or not connections between drugs and violence are a matter of concern in formulating national policy on drugs, it seems important from the standpoint of policy on violence control to examine what is known about how violence is affected by the use of alcohol and other psychoactive drugs, by the marketing of illegal drugs, and by policy interventions to control those activities. From an intellectual perspective, studying how violence is related to psychoactive drugs is of special interest because it demonstrates so clearly the basic premise of Chapter 3that violent events arise from interactions that cut across the biological, psychosocial, and macrosocial levels. At the biological level, pertinent neurobiologic relationships
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Page 183 have been discovered between certain psychoactive drugs (including alcohol) and violence, but certainly no basis for a blanket assertion that taking any of them causes people to behave violently. To start with, each of these drugs produces its own distinct array of biological changes; their effects on the body are not alike. For any drug, the particular changes depend on the acute dose level, the long-term pattern of drug use, and whether the concentrations in the brain and body are rising or falling. How these changes affect aggressive or violent behavior depend not only on interactions with endocrine, neurochemical, and genetic mechanisms, but also on interactions with processes at the micro- and macrosocial levels. The link among alcohol, other psychoactive drugs, and violence turns out to be not an example of straightforward causation, but rather a network of interacting processes and feedback loops. In this chapter we examine patterns of violence related to the use of alcohol and other psychoactive drugs, evidence on the multiple connections that account for the relationship, and findings about the effects of interventions for controlling alcohol- and drug-related violence. To study these relationships, one would like to manipulate the variables hypothesized to be causal and to measure the change in violent behavior. Efforts to adhere to this scientific ideal are properly constrained, of course, by technical and ethical limitations on measurement and manipulation. Therefore, quite different methods are used at different levels, and available methods are limited in terms of both the precision of statements that can be made and our confidence in them. In general, our statements become less precise and more speculative as the studied behavior more closely resembles human violent behavior in the community. In contrast to pharmacological relationships, which are often studied in controlled experiments with human or animal subjects, evidence about social-level relationships between psychoactive drugs and violence is more fragmentary. It consists primarily of analyses of cross-sectional variation at different points in time (when different drugs were in vogue), a few ethnographic studies conducted during times of community transition, and facts about changes in particular communities at particular times. Necessarily, therefore, our arguments and conclusions at this level are more speculative than those at other levels. With these cautions in mind, we turn now to a discussion of patterns of violence and the use of alcohol and other psychoactive drugs.
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Page 184 Patterns of Use and Violence Alcohol Situational Drinking Most studies of alcohol use and violence focus on situational relationships between episodes of drinking and violent events; in general, pre-1981 studies find alcohol use by the perpetrator or the victim immediately before more than half of all violent events (Greenberg, 1981). More recent data confirm these findings: between 1982 and 1989, the prevalence of liquor use by offender or victim in Chicago homicides fluctuated between 32 and 18 percent, while the prevalence of other drug use rose only from about 1 to about 5 percent (Block et al., 1990). The Drug Use Forecasting (DUF) program, in use in 22 cities, asks voluntary samples of felony arrestees whether they used alcohol within 72 hours before committing the crime for which they were arrested. During 1989, 59 percent of males and 53 percent of females arrested for violent Uniform Crime Reports index offenses reported such alcohol use. In a 1986 national survey of state prison inmates, the fraction who reported having used alcohol just before committing their crimes was smallerabout 33 percent for convicted rapists, robbers, and assaulters (Bureau of Justice Statistics, 1990:Table 14). The difference between arrestees and prison inmates would be expected if a disproportionate share of the alcohol-related incidents involved acquaintances who were reluctant to press charges and appear as witnesses. These prevalence data are, of course, only suggestive. They are not sufficient to demonstrate that alcohol use increases the risk of violence. Greenberg's (1981) review found substantial alcohol involvement in nonviolent crimes as well as violent ones, and alcohol use prevalence rates in the DUF samples were nearly identical for violent and nonviolent offenses. Prevalence data are not sufficient to show that alcohol use or intoxication increases the general risk of violence. To test that hypothesis with prevalence data, one would need a benchmark: the fractions of people not involved in violence or crime while drinkingwith appropriate adjustments for demographic characteristics of participants, time of day, day of week, and place of occurrence. The panel has been unable to locate or construct such benchmark prevalence data. However, an array of studies discussed later in this chapter finds connections between situational drinking and aggressive or violent behavior at the biological, social, and cultural levels.
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Page 185 Chronic Drinking Only a few studies exist of the relationship between chronic drinking and potentials for violent behavior. In one sample of diagnosed alcoholics, 29 percent had a history of serious violence, including weapon use and inflicting injuries requiring medical attention (Shuckit and Russell, 1984). More importantly for our purposes, comparisons show that within otherwise comparable samples, problem drinkers are more likely than others to have histories of violence. In studies of prison inmates, those classified as "heavy" or "problem" drinkers had accumulated more previous arrests for violent crimes, were more likely to have been incarcerated for a violent crime, and reported higher average frequencies of assaults than did other inmates (see review by Collins, 1986). In a sample of Finnish juvenile delinquents, Virkkunen (1974) found an arrest rate for violent crimes of 22 percent for those who had also been arrested for drunkenness, compared with 12 percent for delinquents without a drunkenness arrest; a similar differential, 47 to 36 percent, was found for property crimes. Studies of the prevalence of alcoholics among violent offenders indicate that alcoholism has been diagnosed in 20 to 40 percent of convicted murderers, 20 to 30 percent of convicted robbers, and 30 to 40 percent of convicted aggravated assaulters (Greenberg, 1981). These fractions are similar to those found among convicted property offenders. Other Psychoactive Drugs Compared with alcohol, there are relatively few sources of data on patterns of drug use and violence. These sources and studies provide the following picture: (1) In 1989, 60 percent of arrestees for violent offenses tested positive for at least one illegal drug1 about the same fraction as those arrested for public order offenses, slightly less than those arrested for property crimes and sex offenses, and, as expected, far less than those arrested for drug offenses. (2) Users of certain drugs2 commit violent crimes at higher individual annualized frequencies than do nonusers, and violent crime frequency increases with drug use frequency. (3) The risk of drug-related homicide varies by placefrom perhaps 10 percent of all homicides nationwide, to a third or more in certain cities, to more than 70 percent in high-risk areas of some citiesas well as over time, in ways that vary from area to area.
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Page 186 Use Among Arrestees Data on the prevalence of drug-positive tests among arrestees are available from the DUF program, in which samples of arrestees are voluntarily tested for 10 drugs other than alcohol (see note 1). In 1989, for males and females combined, 60 percent of arrestees for violent crimes tested positive for at least one of these drugs in 1989just a few percentage points above the fraction who reported using alcohol. Higher drug-positive rates occurred among arrestees for public order offenses (62 percent), property and sex offenses (66 percent), and drug offenses (83 percent). Compared to male arrestees, the drug-positive rates for female arrestees were 3 to 6 percent lower for both violent and property offenses, about the same for drug offenses, and 7 percent higher for public order offenses including prostitution, for which drug use is prevalent. These 1989 drug-positive rates are 1 to 5 percent lower than 1988 levels for all crime-by-gender groups. They are toward the high end of a 1986 range reported for Washington, D.C., by Wish et al. (1986) and Toborg et al. (1986). By combining data for all (violent and nonviolent) felony arrests from the 22 cities, about 20 percent of all arrestees tested positive for two or more of the drugs. By themselves, these figures are difficult to interpret. Because the urine samples are collected at the time of arrest, they convey little information about drug use at the time of the offense for persons who were not arrested at the scenetraces of drug use leave the body at different rates for different drugs. Even absent this problem, the lower prevalence of positive tests among arrestees for violent offenses compared with arrestees for other offenses would argue against the presumption that using psychoactive drugs causes violent offending. The presumption is further weakened by the conclusion of Chaiken and Chaiken (1990) that only small fractions of adolescent and adult drug users ever commit a "predatory" offense (i.e., robbery or other crime for gain). Finally, without baseline measures of the prevalence of drug users among community residents who are not arrested, one cannot assess how much more common drug use is among criminals than among others in the community. Violence Frequencies Studies of offender samples consistently find that users of certain illegal psychoactive drugs have higher individual annualized frequencies for such violent offenses as robbery, armed robbery,
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Page 187 and assault than do nonusers of drugs (Blumstein et al., 1986; Chaiken and Chaiken, 1990; Cohen, 1986; Johnson et al., 1985). The relationship holds over a variety of definitions of drug use: heroin addiction and use (Ball et al., 1983; Chaiken and Chaiken, 1982); daily heroin and cocaine use; and multiple illicit drug use (Elliott and Huizinga, 1984). Because use of multiple drugs including alcohol is so common in offender populations (Wish and Johnson, 1986), available data do not permit us to relate differences in offending rates to specific drugs. Elliott and Huizinga (1984) report the only evidence that partially conflicts with this general conclusion, based on respondents to the longitudinal National Youth Survey (NYS). In 1976, multiple illicit drug users in their sample reported an average robbery incidence (7.2 per person per year) more than double that for nonusers (3.1). In 1980 the relationship was reversed: multiple illicit drug users reported an incidence of only 6.4, compared with 13.1 for nonusers. As noted by Chaiken and Chaiken (1990), this may reflect decreased participation in robbery as sample members move out of the teenage years, or the possibility that subjects who are both multiple illicit drug users and robbers may drop out of the NYS sample over timean indication of the importance of efforts to minimize attrition in longitudinal studies. These descriptive patterns, of course, are not explanations. They are consistent with predatory offending to raise money for drugs, with individual differences or community characteristics that encourage high levels of both drug use and violent offending, and even with a pharmacological effect of drug use on behavior. These and other plausible explanations are considered later in this chapter. Drug Use and Homicide Rates Illegal psychoactive drug use and marketing are clearly implicated in a substantial share of urban homicides, but the relationship is far from the uniform, straight-line relationship claimed by some policy makers (Isikoff and Sawyer, 1990). Although estimating the fraction of all homicides classified as "drug related" involves judgments and approximations, two national estimates from the early 1980s are fairly consistent at 10 percent (Harwood et al., 1984) and 9 percent (Goldstein and Hunt, 1984) for 1980. Urban rates are higher and rose substantially during the 1980s (Goldstein, 1989). Inciardi (1989) found substantial differences in homicide trends across six cities between 1985 and 1988-1989, as their local crack
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Page 188 Figure 4-1 Homicide rates, 1985-1989; cocaine users among male arrestees, 1989. SOURCE: Compiled in Inciardi (1989). epidemics unfolded. Homicide trends during those years varied from decreases in Detroit and Los Angeles to an increase of more than 350 percent in Washington, D.C. For the five DUF participants among the six cities compared by Inciardi, Figure 4-1 extends Inciardi's trends through the end of 1989 and relates them to DUF data on the fraction of 1989 male arrestees testing positive for cocaine, including crack. Neither the levels nor the trends of homicide rates in those cities show any consistent relationship to the prevalence of cocaine users among male arrestees. New York, with the highest cocaine prevalence of the five cities, and Los Angeles, with the second lowest, have the lowest homicide rates. The New York, Miami, and D.C. data resemble, if anything, an inverse relationship between homicide rates and arrestees' cocaine use. Clearly, the aggregate-level relationships between cocaine use and homicide trends defy simple straight-line description.
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Page 189 Pharmacological Links Between Drug Use and Violence Alcohol Experimental and ethological (i.e., seminatural setting) studies demonstrate that low acute doses of alcohol temporarily increase, and high doses temporarily decrease, aggressive behavior in many animal species, including fish, lower mammals, primates, and humans. The increased aggression is associated with the generally arousing effects of alcohol in the early phases of its action; what happens during the later phases, when dysphoric effects occur, has not been well studied (Babor et al., 1983). Chronic alcohol administration to rats causes an increase in their rate of injurious aggression as a response to social provocations, and there is preliminary evidence of a similar pattern in primates. These patterns for other animals are consistent with those previously discussed for humans: high prevalence and incidence of violent crimes among diagnosed alcoholics, and a high fraction of alcoholics among violent offenders (Miczek et al., Volume 3). Conventional wisdom sometimes explains these effects in terms of disinhibiting effects of alcohol that are presumed to release aggressive impulses from inhibition by the brain. Yet the evidence from three decades of studies of animals and humans clearly demonstrates that there is no simple dose-response relationship. Rather: "whether or not alcohol in a range of doses … causes a certain individual to act aggressively more frequently or even to engage in 'out of character' violent behavior depends on a host of interacting pharmacological, endocrinological, neurobiologic, genetic, situational, environmental, social, and cultural determinants" (Miczek et al., Volume 3). These relationships are discussed in the following pages, drawing heavily on comprehensive reviews by Miczek et al. (Volume 3) and Fagan (1990). Endocrinological Interactions Statistical associations between alcohol use and human sexual violence raise the possibility that alcohol consumption might stimulate violent behavior through the endocrine system. Actually, higher alcohol doses reduce testosterone concentrations through action on the testes and livera process that is incompatible with the presumption (Van Thiel et al., 1988). However, in experiments
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Page 190 with rodents and primates, acute low alcohol doses were found to increase aggressive behavior in individuals who already had high blood testosterone levels by more than in other individuals, presumably as a result of testosterone action in the brain. The fact that males are more likely than females to behave violently after consuming alcohol also suggests the possibility of an endocrinological interaction. However, no relevant experimental evidence exists, and correlational analyses suggest that the gender differential is likely to reflect social factors that lead males to expect greater aggression-heightening effects from alcohol than do females (Crawford, 1984; Gustafson, 1986a, b). Neurobiologic Interactions Many neurobiologic explanations have been offered for the effect of alcohol on the central nervous system. At least a few of these are consistent with nonexperimental evidence and relate specifically to aggressive or violent behavior, but none has been confirmed through experiments. In one sample of violent Finnish alcohol abusers, abnormally low cerebrospinal fluid concentrations of the serotonin metabolite 5-hydroxyindoleacetic acid (5-HIAA) were correlated with poor impulse control (Linnoila et al., 1983; Virkkunen et al., 1989a, b). But this correlation could reflect either that poor serotonergic functioning interacts with alcohol to cause violent behavior, or that chronic alcohol abuse interferes with serotonergic functioning simultaneously with other effects on potentials for violent behavior. Low serotonin metabolism appears to be linked to a low response to glucose challenge tests in alcoholic violent offenders, suggesting a possible interaction among predispositions toward violent behavior, alcoholism, and hypoglycemia. In recent animal experiments, pharmacologically blocking the GABAA/benzodiazepine receptor complex inhibited several common behavioral effects of alcohol, including stimulating aggressive behavior in rats and monkeys (Weerts et al., in press). These findings suggest that the GABAA/benzodiazepine receptor complex may be involved in the aggression-heightening effect of alcohol doses. Future studies of the GABAA/benzodiazepine receptor complex need to examine its role in promoting human aggression under the influence of alcohol. Some evidence also suggests alcohol is related to violent human behavior through effects on electrical activity in the brain. In one small sample of people who had committed a violent or
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Page 191 antisocial act, alcohol doses produced an electroencephalogram (EEG) abnormality consistent with temporal lobe damage that is aggravated by the alcohol (Marinacci and von Hagen, 1972). A more recent study found a reduced P300 component of event-related potentials in violent but not nonviolent alcoholics (Branchey et al., 1988). Genetic Interactions There are consistent demonstrations of genetic bases for alcohol abuse (Goodwin, 1973) and for antisocial personality (Schubert et al., 1988), a psychiatric category for which some of the diagnostic criteria are violent behaviors. The fact that they frequently co-occur raises the possibility of some common elements in their genetic bases. Whether the two bases are independent or not is in controversy, with Cadoret et al. (1985) claiming independence and Cloninger et al. (1989) claiming a link for one subtype of alcoholic. One recent study (Grove et al., 1990) involved too small a sample to reach firm conclusions, and, surprisingly, the panel could find no relevant animal studies of this issue. Other Psychoactive Drugs Biological links between psychoactive drug use and violence differ by type of drug, amount, and pattern of use. Use of marijuana or opiates including heroin in moderate doses temporarily inhibits violent and aggressive behavior in animals and humans. In animals, withdrawal from opiate addiction leads pharmacologically to heightened aggressive and defensive actions that last beyond other physiological withdrawal symptoms. Although the same may be true of humans, performing comparable research on addicted human subjects is complicated by multiple pharmacological, conditioning, and social processes that are difficult to disentangle. Chronic use of opiates, amphetamines, marijuana, or PCP eventually alters the nervous system in ways that disrupt social communicationsan effect that may increase one's involvement in altercations that escalate to violence. Amphetamines, cocaine, LSD, and PCP resemble one another in terms of their pharmacological links to violent behavior. Small acute doses increase competitiveness, volubility, and other socially acceptable aggressive behaviors, but are not known to increase the risk of violent behavior. Higher doses seem to cause generally disorganized behavior, including occasional violent outbursts
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Page 192 in a subset of individuals. Long-term frequent use may change the nervous system in ways that induce psychosis, and violent behavior sometimes occurs during drug-induced psychosis. But the frequency of such episodes varies from sample to sample and seems highest among drug users with preexisting psychopathology. These findings are developed further in the following pages. (See Miczek et al., Volume 3, for more complete discussion and supporting citations.) Opiates Doses of morphine and other opium derivatives temporarily reduce aggressive behavior in animals and violent behavior in humans, according to a large number of studies. While occasional heroin use offers humans the feeling of well-being, chronic use affects mood and behavior in more complex ways. Chronic use reduces social interactions in animals and often leads humans to feelings of confusion, hostility, and suspicion; these in turn may increase the risk of violent behavior in future interactions. Chronic use of opiates leading to addiction also modifies the neuroreceptors for opioid peptidesopiate-like chemicals produced within the body. Studies of rodents, cats, and primates in the last decade have shown that such long-term alteration impairs the animals' abilities to communicate while under stress. Extrapolating this relationship to humans, the addiction effect could disrupt individuals' social communications in ways that increase their risks of violent behavior or victimization during subsequent stressful interactions. Animal studies over 25 years have demonstrated that withdrawal from opiates increases the probability of heightened aggressive and defensive acts that continue after other withdrawal symptoms have subsided. Studies of rodents indicate that brain dopamine and noradrenergic receptors undergo marked changes during withdrawal from opiates. This suggests that drugs such as clonidine may be useful in managing human aggression during withdrawal from heroin, and clinical evidence in humans provides some support. Relationships involving opiate addiction, withdrawal, and violent behavior may be amplified by preexisting feelings of rage among heroin addicts. Elevated prevalences of these feelings in opiate addicts have led some to theorize that some persons may become addicted in the course of seeking relief from feelings of
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Page 210 have produced a delayed decrease in violent crimes reported to the police. However, the effect is uncertain because the experimental controls broke down (Uchida et al., 1990). Drug-related police crackdowns are intended to achieve additional disruption through the high visibility associated with police saturation of a small target area. Crackdowns in Lynn and Lawrence, Massachusetts, New York City, Philadelphia, Oakland, California, and Washington, D.C., have been studied in some depth (Kleiman, 1986; Uchida et al., 1990). In the short run, these crackdowns reduced the volume of illegal drug sales on the streets in the targeted area. However, there is controversy over the extent to which the crackdowns merely moved the drug markets off the street into less visible locations in high-rise housing projects, displaced robberies and burglaries to surrounding areas, and accelerated a downward trend in the homicide rate that was occurring throughout the city at the same time. The evaluators of the Oakland effort made perhaps the only supportable generalization, that success in police crackdowns requires three interrelated elements: a highly committed police department, a receptive community, and a drug market that is not yet too firmly entrenched (Uchida et al., 1990). Currently, three comprehensive evaluations of how police activity affects drug trafficking and violent crime are under way in Pittsburgh, Kansas City, and Jersey City, under the National Institute of Justice Drug Market Analysis Program. With the aid of geocoding, the program will permit geographic analysis of police activity, drug marketing, and violent crime levels, so that both local and displacement effects can be observed. Police cooperation with the community in disrupting illegal drug markets includes meetings with community groups, interviews with citizens to inform them about early signs of developing drug markets and a telephone hotline for reporting suspicions, and distributions of leaflets about illegal psychoactive drugs and markets. This variety of community-oriented policing requires a major reorientation of police priorities that permeates through all ranks from the chief down to patrol officers. In one attempt to evaluate community cooperation as a drug market disruption tactic using a pretest/posttest design, the intervention was delivered in a disjointed and inconsistent way and failed to demonstrate any effects on robberies or violent crime, relative to a control beat (Uchida et al., 1990).
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Page 211 Research and Evaluation Needs This chapter has discussed findings about a number of links between violence and psychoactive drugs including alcohol. While progress has been made in understanding those links and using them to reduce violence, much remains to be done. We consider the following areas to be most important in future research and evaluation programs: (1) developing medications to reduce drug craving and to reduce the aggression-promoting effects of alcohol use; (2) male-female differences in the link between alcohol use and violent behavior; (3) other individual differencesbehavioral, genetic, and neurologicalthat distinguish people who behave violently while drinking alcohol from those who do not; (4) relating different combinations of multiple psychoactive drug use pharmacologically to aggressive and violent behavior in humans and other animals; (5) relating the various methods and patterns through which users commonly take psychoactive drugs to their patterns of violent behaviorin particular, ascertaining whether the rapid access of smoked "crack" cocaine to the brain produces perceptual distortions or violent behaviors that do not occur with powdered cocaine; (6) genetic processes that may influence the relationship between chronic alcohol abuse and aggressive or violent behavior in humans and other animals; (7) relationships between levels of violence related to illegal drug distribution and demographic and socioeconomic processes in the surrounding communities; (8) the incidence of violence that is indirectly related to alcohol or other drug use through incidents such as arguments over debt repayments, over the use of family money, and over time spent away from home; (9) profiles of the prevalence of alcohol and other psychoactive drug use by time of day and day of week, and by demographic and socioeconomic categories, as benchmarks for analyzing their causal role in violent events; and (10) evaluations using randomized experiments to test how the following approaches to reducing drug consumption affect violence levels: community- and school-based substance abuse prevention programs, urinalysis monitoring of drug-positive arrestees for violent offenses during pretrial release, substance abuse treatment
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Page 212 for incarcerated drug-using violent offenders with coordinated postrelease follow-up in the community, and police disruption of illegal drug markets in cooperation with local community-based organizations. Notes 1 The urine specimens are tested for cocaine, opiates, marijuana, PCP, methadone, benzodiazepine (Valium), methaqualone, propoxyphene (Darvon), barbiturates, and amphetamines. Samples are collected at the time of arrest on a voluntary basis; an average of 80 percent of arrestees voluntarily cooperate. Test criteria are set to detect use of most drugs in the preceding 24 to 48 hours, but marijuana and PCP can be detected for several weeks after use. 2 Among studies of this relationship, many group all illegal drugs together. Those that distinguish among drugs usually list cocaine, heroin, amphetamines, barbiturates, and hallucinogens other than marijuana (Elliott and Huizinga, 1984). 3 Burglaries entail a risk of violence if the burglar encounters an occupant of the property. 4 Data from the experiment can be used to study how pretrial rearrest probability is related to positive test results because, according to Toborg et al. (1986), pretrial release was rarely revoked following a positive test result or even failure to show up for testing. References Adler, P.A. 1985 Wheeling and Dealing: An Ethnography of an Upper-Level Dealing and Smuggling Community. New York: Columbia University Press. Anderson, E. 1990 Streetwise: Race, Class, and Change in an Urban Community. Chicago: The University of Chicago Press. Anglin, M.D., and G. Speckart 1988 Narcotics use and crime: A multisample multimethod analysis. Criminology 26(2):197-233. Babor, T.F., S. Berglas, J.H. Mendelson, J. Ellingboe, and K. Miller 1983 Alcohol, affect, and the disinhibition of verbal behavior. Psychopharmacology 80:53-60. Ball, J.C., J.W. Schaeffer, and D.N. Nurco 1983 The day-to-day criminality of heroin addicts in BaltimoreA study in the continuity of offense rates. Drug and Alcohol Dependence 12:119-142. Blanchard, R.J., K. Hori, and D.C. Blanchard 1987 Ethanol effects on aggression of rats selected for different levels
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Representative terms from entire chapter: