Research Essay

Aggression and Violent Behavior 34 (2017) 113–116

Contents lists available at ScienceDirect

Aggression and Violent Behavior

Gun violence and substance abuse

Gina Banks, Kyla Hadenfeldt, Madeline Janoch, Carol Manning, Karen Ramos, David A. Patterson Silver Wolf ⁎ Washington University in St Louis, Brown School of Social Work, 1 Brookings Drive, Campus Box 1196, St Louis, MO 63130, United States

⁎ Corresponding author. E-mail addresses: [email protected] (G. Banks), f.hade

(K. Hadenfeldt), [email protected] (M. Janoch), c.mannin [email protected] (K. Ramos), [email protected]

http://dx.doi.org/10.1016/j.avb.2017.02.002 1359-1789/© 2017 Elsevier Ltd. All rights reserved.

a b s t r a c t

a r t i c l e i n f o

Article history: Received 18 June 2016 Received in revised form 10 February 2017 Accepted 15 February 2017 Available online 16 February 2017

Gun violence and substance abuse are prevalent, widespread public health issues that have recently received a great deal of media and political attention. In order to better understand how these phenomena are linked, this paper aims to explore the relationship between the two. First, it will describe the phenomena of gun violence and substance abuse individually. Next, this paper will detail the intersection of gun violence and substance abuse, including shared antecedents, the effect of intoxication on gun violence, and the effect of criminalization of drug use on gun violence. Finally, it will address treatment and policy recommendations.

© 2017 Elsevier Ltd. All rights reserved.

Keywords: Gun violence Substance abuse Intoxication

Contents

1. Gun ownership and violence. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113 2. Substance abuse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 114 3. Intersection of gun violence and substance abuse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 114 4. Shared antecedents of gun violence and substance use . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115 5. Effect of intoxication on gun violence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115 6. Effect of criminalization of drug use on gun violence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115 7. Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 116

Gun violence and substance abuse are prevalent, widespread public health issues that have recently received a great deal of media and po- litical attention. In order to better understand how these phenomena are linked, this paper aims to explore the relationship between the two. First, it will describe the phenomena of gun violence and substance abuse individually. Next, this paper will detail the intersection of gun vi- olence and substance abuse, including shared antecedents, the effect of intoxication on gun violence, and the effect of criminalization of drug use on gun violence. Finally, it will address treatment and policy recommendations.

1. Gun ownership and violence

The U.S. leads in private gun ownership among developed and de- veloping countries (Bungalore & Messerli, 2013). As such, across the

[email protected] [email protected] (C. Manning), du (D.A. Patterson Silver Wolf).

country, 40% of all households possess at least one firearm (Azrael, Cook, & Miller, 2004). Dimock, Doherty, and Christian (2013) found 37% of U.S. citizens report personally owning a gun, with 13% living with someone who owns a gun. Examining gender, men are three times more likely to own a gun compared to women (37% vs. 13%). Among men, 45% live in gun-owning households compared to 30% of women (Dimock et al., 2013). Considering age, 16% of adults under the age of 30 own a gun, compared to 37% of those over the age of 30. Accounting for race, 31% of gun owners are White, com- pared to 15% of African Americans and 11% of Hispanics (Dimock et al., 2013).

In addition to individual gun ownership statistics, there are trends consistent with geographic regions. According to Azrael et al. (2004), 25% of gun owners reside in the Northeast, while the ma- jority reside in the Pacific States and East South Central regions (35% and 60%, respectively). Within these regions, those living in rural areas are more likely to own a gun compared to those in urban sur- roundings (39% vs. 18%) (Dimock et al., 2013). Higher gun ownership rates in rural areas is predominantly attributed to hunting (Dimock et al., 2013).

114 G. Banks et al. / Aggression and Violent Behavior 34 (2017) 113–116

In 2014, there were 33,599 fatal firearm-related injuries in the Unit- ed States, an average of 646 deaths per week (Centers for Disease Con- trol and Prevention, National Injury Prevention and Control, 2014). Suicide by firearm was ranked fourth as a leading cause of death, with homicide by firearm ranked sixth (Centers for Disease Control and Pre- vention, National Injury Prevention and Control, 2014). Moreover, Azrael et al. (2004) suggest gun ownership is closely linked to violence and crime patterns. They assert “availability of guns for use in crime is closely linked to population prevalence” (p. 44). Coupling this, their findings reveal gun ownership prevalence is positively correlated with gun use in instances of robbery and assault and is closely associated with homicide rates (Azrael et al., 2004). As stated by Bangalore and Messerli (2013), in comparison to other countries, 88 in 100 U.S. citizens own a gun. As a result, for every 100,000 deaths, 10 are gun related. These incident rates are exacerbated by higher accessibility to firearms, increasing the probability for “immediate use for a suicide attempt, es- calating an episode of family violence, or self-defense against an intrud- er” (Azrael et al., 2004, p. 43).

In their research on gun violence from 2010 to 2012 in the United States, Fowler, Dahlberg, Haileyesus, and Annest (2015) found men composed 86% of all firearm deaths, and had an annual death rate 6.5 times higher than women. They also found men were more likely to uti- lize a firearm in a suicide attempt at a rate ratio of 7:1, and were more likely to utilize a firearm in a male-to-female homicide at a rate ratio of 5:1 (Fowler et al., 2015). Young adults aged 25–34 experienced the highest rates of firearm fatality, followed by 15–24 year-olds (Fowler et al., 2015). Of all racial/ethnic groups recognized by the Centers for Disease Control and Prevention, non-Hispanic blacks exhibited the highest overall rates of firearm death (18.1 per 100,000) and was posit- ed by Fowler et al. (2015) to mostly be a function of the highest homi- cide rates seen in the non-Hispanic black community. Comparatively, non-Hispanic whites and non-Hispanic American Indian/Alaska Native communities exhibit the highest rates of firearm suicides (Fowler et al., 2015). In general, 85% of people who attempt to end their life by fire- arm complete suicide (Fowler et al., 2015).

With regard to non-fatal gun injury, almost 70,000 people annually receive nonlethal gun wounds (Fowler et al., 2015) Men, again, are dis- proportionately more likely to be seen in the emergency room, and composed 90% of all firearm injury related visits from 2010 to 2012 (Fowler et al., 2015). Seventy-two percent of people admitted to the emergency room with non-fatal gun injuries were under the age of 35 (Fowler et al., 2015). Considering medical costs and cost of productivity loss, the United States spends about $50 billion each year related to fire- arm injury and death (Fowler et al., 2015). A further consideration to gun ownership and violence is the relationship to substance use.

2. Substance abuse

According to the National Survey on Drug Use and Health (Substance Abuse and Mental Health Services Administration, 2014), 21.6 million Americans aged 12 or older were classified with substance abuse or de- pendence in the last year. Most commonly, individuals report abuse of or dependence on alcohol, marijuana, pain relievers and cocaine. More than half (52.2%) of respondents indicated occasional use of alcohol. Nearly one quarter (22.9%) of respondents reported binge-drinking, while 6.3% reported regular heavy drinking.

Rates of illicit drug and alcohol abuse are highest for those in their late teens through mid-twenties, though rates of illicit drug use are steadily increasing for those in their late 50s and early 60s. The rate of substance dependence or abuse is higher for males (10.8%) than for females (5.8%) (Substance Abuse and Mental Health Services Administration, 2014). In 2013, the rate of substance dependence or abuse was 4.6% in Asians, 7.4% in African Americans, 8.4% for whites, 8.6% for Hispanics, 10.9% for individuals identifying as two or more races, 11.3% for native Hawaiians or other Pacific Islanders, and 14.9%

for American Indians or Alaska Natives. (Substance Abuse and Mental Health Services Administration, 2014).

While rates of drug dependence or abuse are not associated with levels of educational attainment, they are correlated with employment: 15.2% of unemployed adults were classified with substance dependence or abuse compared to full-time (9.5%) or part-time (9.3%) employed adults. Substance abuse is also prevalent in criminal justice populations: 34.3% of adults who were on parole or released from jail in the past year reported drug or alcohol dependence or abuse compared to 8.4% of their counterparts who were not on parole or supervised release. The rate of substance dependence or abuse was 35% among adults on probation, while the rate of substance dependence or abuse for those not on probation was 8% (Substance Abuse and Mental Health Services Administration, 2014).

There are a number of costs associated with substance and alcohol abuse. Abuse of alcohol and illicit drugs costs $417 billion annually in costs related to health care, crime, and lost work productivity (National Institute on Drug Abuse, 2015). Substance abuse is known to be associated with impulsivity, impaired judgment, violence, crime, in- jury, death, and suicide (Branas, Han, & Wiebe, 2016). Although sub- stance abuse and dependence is demonstrably a widespread issue with significant consequences, few who need treatment receive it: only 10.2% of those with substance abuse or dependence disorders re- ceived treatment in 2013 (Substance Abuse and Mental Health Services Administration, 2014).

3. Intersection of gun violence and substance abuse

A strong correlation between gun violence and substance abuse has been suggested in several studies (Sheehan, Rogers, Williams, & Boardman, 2013; Rivara et al., 1997; Reid, 2001). Although few studies exist that focus specifically on gun violence and substance abuse, several studies demonstrate a relationship between substance abuse and crime, gun ownership and violent death. Carter et al. (2013) found binge drinking and illicit drug use were positively correlated with gun posses- sion among youth admitted to an emergency room for assault-related injury. Wintemute (2015) demonstrates that gun owners are more like- ly to engage in binge drinking and heavy drinking. Researchers have also found that substance abuse is a strong predictor of domestic vio- lence (Rueve & Welton, 2008). Substance use is associated with violent death, including homicide and suicide (Rivara et al., 1997; Sheehan et al., 2013). Rivara et al., 1997 found individuals who used both alcohol and illicit drugs were 16 times more likely to commit suicide than the general population, and that individuals who lived with others who used alcohol or other drugs were at an increased risk of homicide, even if they did not use themselves. Sheehan et al. (2013) found 42.2% of victims of violent deaths in their study tested positive for alcohol, 13.5% for opiates, and 40.1% for “other drugs.” Only 12% of victims were found to have no drugs in their system (Sheehan et al., 2013). Reid (2001) found drug use and gun use are positively associated among incarcerated youth, with gun use increasing risk of drug use by 60% and drug use increasing risk of gun use in crime by 34%. In their to- tality, these data present strong evidence for the relationship between gun violence and substance use.

Although causality has not been established, the evidence suggests various explanations for the relationship between the two (Reid, 2001;Sheehan et al., 2013). The first is that gun violence and substance abuse share some of the same risk factors; although neither behavior causes the other, they are often found together due to their shared ante- cedents (Reid, 2001; Sheehan et al., 2013). A second explanation is that some of the immediate consequences of substance abuse, such as im- paired judgment, impulsivity, and agitation, increase the risk of violent behavior, including gun violence (Rivara et al., 1997; Sheehan et al., 2013). A third explanation is that the criminalization of drug use gener- ates a culture of illegal behavior and violence, including gun violence (Cundiff, 2001; Crockett, 2013). Individually, none of these theories

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provides an adequate explanation of the relationship between sub- stance abuse and gun violence, but each offers a unique perspective on the issue that may lead to improved understanding and more effec- tive interventions.

4. Shared antecedents of gun violence and substance use

In her work on the relationship between substance use and crime, Reid (2001) notes a causal relationship between the two is difficult to establish because evidence shows that in some cases, substance use pre- cedes criminal behavior, and in others, criminal behavior precedes sub- stance use. Based on her own research, Reid (2001) found the relationship between substance use and gun violence was even more complicated: while drug use seemed to increase the risk of gun use, al- cohol and marijuana use decreased that risk. Moreover, early gun use was found to be a predictor of later drug use, whereas less serious delin- quency was not (Reid, 2001). Rivara et al., 1997 note individuals who demonstrate aggressive or antisocial behavior as children are more like- ly to engage in heavy drinking as adults. These and similar results sug- gest that rather than either behavior causing the other, both substance use and gun violence are related by a common set of antecedents or risk factors, rather than direct causality (Reid, 2001). Common environ- mental risk factors include weak attachment to family or community, economic disadvantage and interaction with delinquent peers (Reid, 2001; American Psychological Association [APA], 2013). Common indi- vidual risk factors include poor performance in school and early aggres- sive behavior (Rivara et al., 1997; APA, 2013). Since individuals who experience these risk factors are more likely to engage in both behav- iors, it may be more accurate to characterize substance use and gun vi- olence as manifestations of a single underlying problem, rather than as two distinct problems.

5. Effect of intoxication on gun violence

While noting common risk factors among substance use and gun vi- olence may provide valuable information regarding the underlying causes of these behaviors, it does not account for the evidence that gun violence is more immediately related to substance abuse. It may ex- plain the relationship between lifetime substance use and gun violence, but not the relationship between intoxication and violence. Although much of the literature focuses on intoxication and violence in general (not gun violence specifically), evidence for the relationship between intoxication and violent behavior, coupled with evidence that gun pos- session and drug use are often found together (see Wintemute, 2015; Carter et al., 2013), suggest a possible link between intoxication and gun violence.

Several drugs, including alcohol, cocaine, amphetamines, PCP and steroids, are associated with increased risk of violent behavior during intoxication (Rueve & Welton, 2008; Rivara et al., 1997). This increase is most often explained as a result of the physiological and psychological effects of the drugs on the intoxicated individual, such as disinhibition and impaired judgment for alcohol, and agitation and impulsivity for stimulants (Rueve & Welton, 2008; Rivara et al., 1997). Rivara et al., 1997 also note that the belief among drinkers that alcohol causes ag- gressive behavior creates a “self-fulfilling prophecy” such that individ- uals expect to engage in violence when they drink (p. 573).

Sheehan et al. (2013) found that intoxication from alcohol and opi- ates is associated with suicide. In their study, 10.9% of suicide victims tested positive for opiates, and 30.1% were positive for alcohol (Sheehan et al., 2013). Branas, Richmond, Ten Have, and Wiebe (2011) found that alcohol intoxication was associated with increased risk of suicide by firearm. Sheehan et al. (2013) suggest that the psycho- logical effects of these drugs may account for the high rates of intoxica- tion among suicide victims; however they also note that opiates are sometimes the method of suicide, which weakens the evidence of a causal relationship between intoxication and suicidality (Sheehan et

al., 2013). Branas et al. (2011) note that alcohol reduces inhibitions and increases confidence, and suggests that some suicide attempters use alcohol to overcome uncertainty or fear. The findings of Sheehan et al. (2013) and Branas et al. (2011) suggest that while intoxication may not be a direct cause of suicide, availability of alcohol and other drugs may contribute to suicide completion.

6. Effect of criminalization of drug use on gun violence

Whereas the above two explanations of the relationship between substance use and gun violence focus on individual behaviors, the final explanation relies on a systemic view of these issues, and proposes that the relationship between substance use and gun violence is due to the criminalization of drug use, which forces drug users, sellers and pro- ducers into an illegal market, and generates crime and violence (Crockett, 2013; Cundiff, 2001). Cundiff (2001) demonstrates a strong correlation between homicide rate and substance control policy from the mid-1970s to the 1990s, and points to historical data that shows a significant decrease in the homicide rate following the repeal of Prohibi- tion. Jensen (2000) similarly notes the increased homicide rate during Prohibition, and suggests that this is due to the lack of legal, non-violent means of dispute resolution among parties engaged in illegal markets. Since the trade and consumption of alcohol could not take place in the presence of law enforcement, law enforcement could not be relied on to protect victims or punish perpetrators of violence (Jensen, 2000). Cundiff (2001) and Jensen (2000) both argue that drug users and sellers today are in the same position. Cundiff (2001) further suggests that the criminalization of drug sales increases the cost of drugs, forcing drug users to engage in violent crime in order to pay for the drugs. Crockett (2013) argues that the trade routes created by the black market drug trade may be used for the illegal trade of firearms as well, which rein- forces the relationship between the drug trade and gun use.

Blumstein (2011) further demonstrates that, as a result of the War on Drugs, many established gang leaders were incarcerated in the mid-1980s. As gangs were left in the hands of much younger, less expe- rienced leadership, homicide rates among young people increased dra- matically in the early 1990s (Blumstein, 2011). Currently, gang-related homicides account for approximately 25% of all homicides in major cit- ies (Howell, Egley, Tita, & Griffiths, 2011). In a 2012 study of gang-relat- ed homicides in five cities, 27–42% of victims were 15–19 years old, and 25–28% were 20–24 years old (CDC, 2012). 90% of gang-related homi- cides involved firearms (CDC, 2012). It should be noted that these theo- ries are not mutually exclusive.

7. Recommendations

Although the evidence for each of these explanations is far from conclusive, all three perspectives offer valuable insights into the rela- tionship between substance use and gun violence. Each of these per- spectives should be considered when developing policies to reduce substance use-related gun violence. In order to mitigate the effects of gun violence and substance abuse, a multi-faceted, multi-disciplinary approach must be employed in order to effect change on the population, community, family and individual levels. The reduction of gun violence attributed to substance abuse should utilize a prevention focus that ad- dresses the early identification of substance abuse issues with an em- phasis on addressing issues that plague at-risk youth. Many of the programs rated “Effective” by the Office of Juvenile Justice and Delin- quency Prevention involve a punitive aspect and utilize principles of the deterrence theory that can only be sustained with a strong, commit- ted law enforcement alliance. Researchers evaluated the effectiveness of a deterrence program called Operation Ceasefire in Boston, Massachu- setts which employed a problem-oriented policing policy and found that youth homicides decreased to their lowest levels since 1976 (Braga, Kennedy, Waring, & Piehl, 2001). While effective, this program requires significant resource investment from many agencies including

116 G. Banks et al. / Aggression and Violent Behavior 34 (2017) 113–116

law enforcement and social services. In order to achieve long-term gains, programs must be comprehensive and incorporate education, programming, and harm reduction strategies that target this vulnerable population while maintaining a preventive posture.

Based on the research and current policies, more comprehensive gun control should be considered and existing policies and procedures enforced in order to address gun violence on a systemic level. According to Branas et al. (2016), federal law does not prohibit firearm purchases for those who abuse alcohol and there is no system in place to address this during the national background check process. Introducing a sys- tem for medical providers to document and transmit concerns regard- ing individuals with substance abuse disorders who also exhibit a moderate to high risk for committing a violent act should be imple- mented in order to prohibit gun purchases. These policy changes mirror policy initiatives that have been championed by the public health com- munity and focus on the overall reduction of gun violence through proper vetting of those at greatest risk of committing violent acts in ad- dition to those with mental illnesses. Additionally, collaborations with law enforcement are necessary to ensure appropriate measures are taken to remove firearms and other weapons from the possession of in- dividuals with documented substance abuse who pose a current risk of harm to themselves or others. With regard to alcohol, Carr, Porat, Wiebe, and Branas (2010) found that just under half of the United States (19 total) “have no restrictions on ownership, possession, or use of a firearm while intoxicated” (p. 676). In addition to greater knowledge about the impact of alcohol on one's ability to judiciously discharge a firearm, Carr et al. (2010) posited laws limiting firearm usage while under the influence of alcohol or while participating in a substance abuse treatment program could potentially decrease instances of injury and death related to firearms. This hypothesis is based on the significant decrease in motor vehicle deaths following legislative restrictions on driving under the influence (Carr et al., 2010).

Furthermore, the high prevalence of substance use preceding or fol- lowing a violent act necessitates an overhaul in substance abuse treat- ment. The availability, quality, and normalization of substance abuse services must become a national priority that aims to address the de- stigmatization of substance use and substance abuse treatment. Addi- tionally, the adoption of a client-centered treatment approach that fo- cuses on the treatment of the substance use disorder rather than the criminalization of drug use is critical to ensure that individuals access the resources currently in place. This type of approach lends itself to bet- ter client outcomes which will invariably impact the national rates of gun violence. Finally, additional research on gun violence and substance abuse is indicated in order to enrich the body of literature surrounding this topic and inform future laws, policies, and procedures that will shape the future of this country and its management of the challenges surrounding gun violence.

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Additional readings

http://www.cdc.gov/mmwr/preview/mmwrhtml/ss5904a1.htm General data on risk factors for violent deaths https://www.washingtonpost.com/news/wonk/wp/2015/12/03/weve-had-a-massive-

decline-in-gun-violence-in-the-united-states-heres-why/ News article about decline in gun violence; links to decline in alcohol consumption https://www.ucdmc.ucdavis.edu/publish/news/newsroom/9562 Short report on trends in gun violence http://www.pewsocialtrends.org/2013/05/07/gun-homicide-rate-down-49-since-1993-

peak-public-unaware/ Detailed report on trends in gun violence http://www.cnn.com/2015/12/04/us/gun-violence-graphics/ Graphic representations of gun violence trends in the U.S. http://www.ojjdp.gov/pubs/gun_violence/sect01.html Youth and gun violence