Abstract

Substance abuse is closely linked to criminal behaviour, yet the pathways differ across drugs. This paper reviews how alcohol, methamphetamine and heroin disrupt the brain and shape offending. Alcohol’s strong correlation with violent crimes can be explained by the way it damages the prefrontal cortex and hippocampus, which reduces inhibitory control and increases aggression. Methamphetamine causes long-lasting cognitive and emotional impairments by damaging white matter and interfering with the dopamine and serotonin systems. These impairments are linked to violent and acquisitive crime, which is frequently influenced by socioeconomic circumstances. Heroin causes impulsivity, compulsivity and withdrawal-driven desperation, which are particularly linked to property crime, by interfering with the prefrontal cortex, hippocampus and reward circuits. Taken together, these findings show that neurobiological damage interacts with social and economic pressures to amplify risks of offending. Results suggest that each substance disrupts specific brain systems responsible for self-control and decision-making, creating different pathways to criminal behaviour that vary based on individual and environmental factors.

Introduction

There is a complicated relationship between substance abuse and crime, but research has shown that alcohol, methamphetamine and heroin each directly contribute to illegal behaviours through neurobiological effects. In individuals intoxicated with alcohol, aggressive behaviour was linked with activation in the prefrontal cortex (Gan et al., 2015). Methamphetamine damages white and grey brain matter, which affects muscle movement, emotion and communication within the brain (London et al., 2015). Heroin also largely affects the prefrontal cortex, impairing decision-making, judgement and emotional control (Wang et al., 2025). Addictions to alcohol, methamphetamine and heroin affect the brain in distinct ways that impair judgement, increase impulsivity, impair cognitive control and more. Further, these disruptions in neuropsychological pathways contribute to criminal behaviour, showing the psychobiological impacts of each illicit substance and how it shapes offending behaviour.

I. Alcohol

Understanding the relationship between alcohol and the brain calls for an in-depth look at the effects of alcohol. More specifically, there needs to be an understanding of how alcohol affects the regions of the brain that control behaviours and emotions. The usage of alcohol affects parts of the brain that control decision-making, self-control, judgement and aggression (Abernathy et al., 2010) – brain functions which are used while making lawful, pro-social decisions. Psychological experiments further reveal how intoxication leads to a false sense of reasoning, while increasing risk-taking (Steele & Josephs, 1990). Together, these findings highlight that the link between alcohol and crime is not just social, but also rooted in biology. 

RELATIONSHIP BETWEEN ALCOHOL AND THE BRAIN

There has been extensive research on how alcohol has consequential effects on specific areas of the brain. The prefrontal cortex, which is responsible for actions such as decision-making, judgement and self-control, is usually affected by alcohol (Abernathy et al., 2010). Damage to the prefrontal cortex leads to impulsivity and inattentiveness. Additionally, functional magnetic resonance imaging (fMRI) of the frontal lobe, hippocampus and thalamus show that individuals with alcohol abuse disorder experience increased aggression, lowered inhibitory control, issues completing patterned motor movements and decreased obedience to instruction (Kose et al., 2015). Another part of the brain that is affected is the hippocampus, which plays a role in memory, learning and emotional regulation (Meda et al., 2018). Disturbances in this part of the brain often lead individuals to develop gaps in memory and an increased inability to regulate stress (Staples & Mandyam, 2016). Chronic alcohol abuse causes structural changes in the brain, with shrinkage of the prefrontal cortex, hippocampus and cerebellum, resulting in emotional instability and poor behavioural control (Harper & Matsumoto, 2005).

Evidence from a neurotransmitter study shows that the balance between inhibitory and excitatory neurotransmitters is disrupted by alcohol (Palmer et al., 2019). Crews et al. (2005) report that alcohol use leads to reduced levels of gamma-aminobutyric acid (GABA), an inhibitory neurotransmitter with anxiolytic effects, and GABA receptor insensitivity, alongside increased glutamate, the most abundant excitatory neurotransmitter, and glutamate receptor suppression. Elevated levels of glutamate, as reported by Valenzuela (1997), slow cognitive operation, impair memory and cause problems with learning. This inequality in neurotransmitter activity leads to poor judgement and reduced self-awareness. 

RELATIONSHIP BETWEEN ALCOHOL AND CRIME

Alcohol remains one of the most widely abused substances, and its connection to illegal activity and brain function is well documented. Due to the fact that alcohol impairs decision-making, it is strongly associated with violent offences such as assault, domestic violence and homicide. Unlike other drugs, alcohol’s legal status and widespread availability make its impact on crime statistics across nations particularly significant. While sociological explanations, such as poverty and environment, help explain part of this connection, recent experimental research shows that alcohol directly alters brain function in ways that promote criminal behaviour. 

Numerous studies across decades demonstrate a strong correlation between alcohol use and violent/criminal behaviour. A review of literature spanning 20 years revealed a consistently high incidence of violent actions when alcohol was involved, whether consumed by the aggressor, the victim or both, including roughly 40% of assaults and homicides. It is also a common factor in public disorder and property offences (Room & Rossow, 2001). These statistics represent alcohol as a prominent public safety concern, but why is alcohol consistently linked to offending? Criminological work on offender cognition, such as Maruna and Mann’s (2006) analysis of “cognitive distortions”, helps bridge this gap by showing how offenders rationalise. The statistical prevalence of alcohol-related crime and the ways alcohol can distort offender thinking highlight a critical need to understand the underlying mechanisms.

Individual responses to intoxication vary widely, suggesting that sociocultural context, organic predispositions and personality traits significantly influence behavioural outcomes following alcohol consumption (Chalub & Telles, 2006). This variation implies that alcohol does not directly provoke criminal activity, but its effects are mediated by a complex interplay of internal and external factors. While the relationship between substance (alcohol) abuse and crime is multifaceted, the consistent correlation across diverse studies highlights the need for further investigation. 

It is also known that the duration of psychoactive substance use, including alcohol, correlates strongly with increased involvement in criminal acts. Individuals with longer-term dependencies tend to engage in criminal behaviour more frequently. Social and economic disadvantages such as poverty, low self-control and association with delinquent networks tend to intensify this risk. Gender differences have also been observed; males are more likely to commit violent offences and theft, while females are more often engaged in offences directly linked to dependency behaviours. Despite these trends, women remain statistically less involved in criminal activity overall (Namdarian, 2020). Other studies further underscore alcohol’s direct role in criminal incidents. One investigation found that 20% of violent crimes and 7% of non-violent offences could be directly attributed to alcohol use at the time of the incident, suggesting those acts may not have occurred without its influence (Wettlaufer et al., 2021). In another study, a substantial proportion of repeat offenders were found to have been under the influence of alcohol during their offences, with financial desperation and impaired decision-making commonly cited as motivating factors (McKetin et al., 2015). These findings support the broader understanding that alcohol acts not only as a disinhibitor but also exacerbates existing vulnerabilities, leading to elevated rates of criminal behaviour across different populations.

Beyond aggression, alcohol also impairs executive functioning, leading to the risk-taking behaviours observed in crime. Intoxicated participants exhibit deficits in impulsivity control and decision-making abilities, consistently choosing riskier options and showing reduced consideration of long-term consequences (Kerner, 2011). These cognitive impairments suggest that alcohol directly diminishes the ability to evaluate potential outcomes, increasing susceptibility to opportunistic or hazardous behaviours. Maruna and Mann (2006) further document how offenders rationalise their actions post-intake, often attributing poor judgement to intoxication. The comparison between controlled cognitive experiments and qualitative offender studies is enlightening. While laboratory tasks isolate specific decision-making mechanisms, offender interviews reveal how these deficits manifest in real-life contexts, such as property crime, drunk driving or impulsive theft. Both approaches consistently point to diminished executive functioning under alcohol as a key facilitator of risky behaviour. Linking experimental findings to criminological observations demonstrates that alcohol’s impairment of judgement is a central factor in criminality, suggesting that interventions focused on self-control and alcohol regulation could meaningfully reduce risk-related offences.

Alcohol’s effects are also dependent on where and how people drink. Drinking typically occurs more frequently in social settings like bars, parties or festivals. Studies of nightlife districts show that violent crime rates rise in places where alcohol is widely available late at night. Routine activity theory explains this by showing that crime happens when three conditions meet: people who are drunk enough to commit crimes, victims who are too intoxicated to defend themselves and few bystanders who intervene. Cultural attitudes also matter: in some places, drunken aggression is socially tolerated or even expected, encouraging violence, while in other cultures where alcohol use is more controlled, the link to crime is weaker.

Taken together, the evidence demonstrates that alcohol plays a decisive role in shaping patterns of criminal behaviour. Experimental research makes clear that intoxication undermines impulse control and heightens aggressive responses, while criminological data confirms that these tendencies translate directly into violent crime statistics. At the same time, situational and cultural factors amplify alcohol’s effects by creating environments where conflicts escalate and opportunities for offending are abundant. Thus, alcohol must be understood not only as a biological disinhibitor but also as a social catalyst that magnifies risks already present in specific contexts. Recognising this dual role has important implications for prevention: strategies that combine individual-level interventions, environmental controls in nightlife spaces and cultural shifts in attitudes toward drunken aggression are likely to reduce the incidence of alcohol-related crime. By integrating laboratory evidence with real-world observations, it becomes evident that alcohol is not simply a background factor but a prominent driver of violence and disorder in society.

II. Methamphetamine

In order to look at the effect of methamphetamine on criminal behaviour/violence, we must first look at how it permanently affects one’s tolerance, neurochemistry and natural systems in the brain. Countless studies and experiments show a decrease in “white matter” as well as disrupted neurochemistry in the brain, leading to an unnatural amount of dopamine and serotonin in the body and a decrease in normal functioning of memory, behaviour and the ability to make good decisions. Due to this, criminals often forget about the crimes they committed and lack care for the consequences of their actions. The link between methamphetamine, the brain and criminal behaviour is strong and must be examined from multiple viewpoints. 

RELATIONSHIP BETWEEN METHAMPHETAMINE AND THE BRAIN

Methamphetamine has a permanent, irreversible and addictive effect on one’s body and brain, causing rapid decline in attention, memory and mood. These shifts are even more alarming when a tolerance is built towards the substance, especially at a young age, which makes recovery particularly challenging. Specifically, methamphetamine use results in drug dependence, behavioural and neurochemical changes, and chronic brain damage. 

Like many drugs, tolerance and dependence on methamphetamine occurs when the body stops experiencing highs after multiple doses, resulting in the need for a larger dose to elicit the same response. Smith (2022) explains that methamphetamine is a “central nervous system stimulant, meaning many of its effects come from the way it interacts with neurons, monoamine neurotransmitters and receptors in the brain”. Tolerance is directly related to the brain’s neurotransmitter system; therefore, chemicals such as dopamine (associated with happiness) and serotonin (associated with pleasure and relaxation) are deeply affected. Methamphetamine can increase levels of dopamine up to one thousand times, creating intense cravings and addictions (Renew Health, 2025) while boosting serotonin levels for short periods of time after the drug is taken (Smith, 2022). 

In a study that examined changes in the brain through ERI and PET scans, particularly in the basal ganglia responsible for decision-making and our body’s natural reward system, children and adults who took methamphetamine regularly had a reduced amount of dopamine transporter density and dopamine receptors in the brain. Chang et al. (2007) suggest users have to take larger amounts of the substance to get the same pleasurable feeling not only due to tolerance, but also because they have developed a decreased ability to make dopamine naturally. 

Figure 1: Non-Drug User Control vs Methamphetamine User (Wiley Online Library).

Countless studies have shown that methamphetamine addicts also have decreased brain “white matter”, slowing responses, memory and learning (Mishra, 2007). This decrease in white matter can be permanent and slows down blood flow to the brain.

RELATIONSHIP BETWEEN METHAMPHETAMINE AND CRIME

Methamphetamine stands among the most destructive and pervasively misused illicit substances; its imprint on both neurocognitive function and criminal behaviour is extensively documented. With prolonged abuse, methamphetamine impairs functions responsible for impulse control, aggression regulation and decision-making. This neurological degradation, in turn, mires individuals in patterns of behaviour marked by a heightened inclination towards both violent and economically motivated offences.     

However, the findings of Gizzi and Gerkin (2010) suggest that the correlation between methamphetamine use and criminal behaviour is predominantly sociological and economically motivated, rather than inherently violent. The connection between methamphetamine use and violent crime was found to be inconsistent; however, the association with drug-related offences and property crimes proved significantly more prominent. Specifically, 57.1% of regular methamphetamine users reported engaging in criminal activities related to possession, distribution or dealing to support their substance dependence, compared to only 14% of non-users. Similarly, 32.7% of methamphetamine users reported committing property crimes driven by financial necessity, whereas this figure was just 14% among non-users. Therefore, from the data, it remains unclear whether methamphetamine use directly contributes to criminal behaviour or if the observed relationship is primarily driven by environmental and socioeconomic factors. This stance is further supported by countless studies, such as the research conducted by Goldsmid & Wilis (2016), which examined over 1,100 police detainees and found a similarly strong association between methamphetamine use and economically motivated crime. In this study, methamphetamine users were significantly more likely to engage in income-generating criminal activities such as drug dealing, shoplifting and other forms of acquisitive crime compared to non-users. Specifically, users were approximately 4.5 times more likely to report earning income through acquisitive crimes, even when accounting for the use of other illicit substances, highlighting a strong link between methamphetamine use and economically motivated criminal behaviour. These findings emphasise the importance of addressing underlying social and economic conditions when tackling the criminal behaviours associated with methamphetamine use.

It is difficult to determine whether the relationship between methamphetamine addiction and violent crime stems directly from the pharmacological effects of the drug or is instead a consequence of the environments users are exposed to, where violence is prevalent. The national trauma study by Aguilar et al. (2023) found that methamphetamine-positive patients were significantly more likely to present with penetrating trauma – namely, stab wounds (10.5%) and gunshot wounds (8.3%) – compared to methamphetamine-negative patients (4.5% and 4.6%). However, despite these significant associations, the authors acknowledged a crucial limitation: the inability to determine whether patients were the victims or perpetrators of these injuries. Moreover, while methamphetamine-positive patients were more likely to experience early medical complications, such as needing ICU care or emergency surgery, their initial injuries and vital signs were similar to those who tested negative. This indicates that the connection between methamphetamine use and violent injury may not be caused by the drug alone. Instead, it likely reflects the broader social conditions in which many users live, including poverty, unstable housing and environments where violence is more common. These factors increase both the likelihood of use and the chances of being involved in violence.

While establishing a direct causal link between chronic methamphetamine use and violent behaviour remains complex, McKetin, McLaren, Riddell and Robins (2006) identified a significant correlation specifically in cases of methamphetamine-induced psychosis. This deterioration, characterised by persecutory delusions and a detachment from reality, substantially increases the likelihood of unpredictable and violent behaviour. As a result, the relationship between methamphetamine use and violence should be conceptualised as conditional, contingent upon the severity of use and the individual’s neurological susceptibility, rather than as a direct or inevitable consequence of the drug.

Gender is another factor to consider. Research by Daiwile, Jayanthi and Cadet (2022) shows that women tend to be more sensitive to the effects of methamphetamine, experiencing stronger behavioural and subjective responses such as increased impulsivity, cravings and withdrawal symptoms compared to men. This is because of variations in genes related to brain function and neuroadaptation, such as those involved with cholinergic receptors, GABA receptors and brain-derived neurotrophic factors, possibly making women more vulnerable to the cognitive and emotional impairments caused by methamphetamine. These sex-specific genetic factors likely explain why women tend to experience more severe psychiatric symptoms, including anxiety, depression and psychosis, which can affect their decision-making and emotional regulation, resulting in a higher risk of engaging in risky or illegal activities to cope or access drugs. Additionally, women tend to relapse more frequently and have heavier lifetime use, which could expose them repeatedly to environments where criminal activities, such as drug trafficking or theft, are more common. Biological factors, like gene polymorphisms affecting brain function, may also make women more susceptible to psychotic behaviours, which could further contribute to criminal involvement. On the other hand, men show a stronger link between impulsivity and the duration of methamphetamine use, which may lead to different patterns of drug-related crime, often characterised by more direct aggression or violent behaviour. Men also tend to experience higher levels of depression connected to cravings, indicating distinct psychological pathways that influence their behaviour and potentially their involvement in criminal activities (Cadet et al., 2022). 

Overall, the neurological effects of methamphetamine use play a critical role in increasing the likelihood of criminal behaviour. The drug’s impact on the brain, particularly on regions responsible for impulse control, decision-making and emotional regulation, undermines an individual’s ability to make rational choices and prevent risky actions. However, it is important to recognise that these neurological changes do not act in isolation. The broader social and economic environments in which individuals live significantly shape how these brain impairments translate into actual behaviour. Factors such as poverty, lack of access to education and employment, unstable housing and limited social support can amplify the challenges faced by methamphetamine users, making them more vulnerable to criminal involvement. Therefore, the relationship between methamphetamine and crime is multifaceted, with neurobiological damage providing a foundation upon which environmental and socioeconomic stressors can exert their influence. 

III. Heroin

When looking into heroin addiction and the crimes committed by addicts, it is important to understand how the brain responds to the use of this substance. Through research, we can see that heroin mostly affects parts of the brain that control reward pathways, emotions, impulse control, decision-making, learning, memory and vital bodily functions like breathing, heart rate and blood pressure. The deficits caused by heroin use provide a better understanding of how heroin addiction culminates in criminal behaviour.

RELATIONSHIP BETWEEN HEROIN AND THE BRAIN

Heroin impacts multiple different sections of the brain, including the ventral tegmental area (VTA) and the nucleus accumbens (NAcc), where it increases the release of dopamine into the brain’s reward circuit, creating a strong feeling of euphoria. A study by Seifert et al. (2015) discovered that the volume of the NAcc is smaller in heroin addicts than in non-addicted patients. Additionally, they found that “depression score was negatively correlated with left NAcc volume in patients, whereas a positive correlation was found between the daily opioid dose (heroin) and the volume of the right amygdala” (Seifert et al., 2015). 

Furthermore, a study by Wang et al. (2025) examined the effects of heroin on the prefrontal cortex and social stimuli. Using fiber photometry calcium imaging, they monitored calcium-dependent fluorescent signals in PrL CaMKII-expressing neurons during drug seeking and social interaction following 14 days of abstinence from heroin use. The study found that “GCaMP6f signals in PrL CaMKII-expressing neurons were increased when heroin-associated cues were presented” (Wang et al., 2025). The use of heroin decreased PrL CaMKII-expressing neurons during social investigation. This is a strong factor in why heroin addiction and relapse are so strong.

Figure 2: Z score of neural activity over time in response to a cue.

According to a study by Eisch et al. (2000), chronic heroin usage decreases the growth and development of nervous tissue (neurogenesis) by 42%, delaying neurological development. Opioids like heroin also affect the brain stem that controls breathing, heart rate and blood pressure; this interference can be fatal.

Heroin severely disconnects critical regions of the brain and body, from affecting decision-making in the prefrontal cortex to suppressing memory in the hippocampus. These changes in the brain help to explain the cycle of addiction and relapse, and also the declining self-control, problem-solving skills and emotional regulation among addicts.

RELATIONSHIP BETWEEN HEROIN AND CRIME

The United States Office of National Drug Control Policy states that “heroin use [] appears to be most strongly causally related to property crimes” (ONDCP, 2013) and acknowledges that there is insufficient evidence for direct connections between heroin and violent crimes. By interfering with the brain’s control systems, heroin may be responsible for a behavioural shift towards immediate reward and away from long-term gain. Kang et al. (2024) discovered that heroin users “displayed less sensitivity to loss, shown as lower loss aversion and loss impact scores”. They also scored higher on impulsivity. Reid et al. (2018) demonstrated how impulsivity contributes to a downward spiral: impulsive heroin users cause harm to their lives because of their drug use; this mounting harm then fuels depression and stress. This cycle creates the perfect conditions for property crime: unhappy, irrational, impulsive and overburdened people are more vulnerable to seeking short-term reward without considering the long-term risk. Longitudinal data supports the acquisitive-crime link: Pierce et al. (2017) found that “initiation of opiate use increased the [offending] rate ratio by 16% for males [and] 100% for females”, with the largest increases in non-serious acquisitive offences and crime rates that “increased four-to sixfold during periods of active addiction” (Pierce et al., 2017). It is worth noting that there are limitations to this literature. Kang et al. (2024) employed a cross-sectional design with only male participants, which may not reflect real-life offending behaviour adequately, as it fails to distinguish pre-existing impulsivity from drug-induced alterations. Also, Reid et al. (2018) employ self-reports characterised by ambiguous directionality. Another factor that is important to consider, which the ONDCP points out, is that many studies fail to consider alcohol and other drugs simultaneously, making heroin’s significance seem higher than it is. Finally, while Pierce et al.’s (2017) UK registry evidence is methodologically sound, it limits itself to the UK.

In a clinical sample of 219 participants, withdrawal was linked to criminal activity in 64.4% of cases, with 76.19% relating to property crimes and 35.48% to personal crimes (Bacciardi et al., 2012). However, hostility increased significantly for heroin users and those with antisocial personality disorder (ASPD) (Bacciardi et al., 2012). Similarly, Rafaiee et al. (2013) found that among heroin-using prisoners in Zahedan, 52.4% had committed robbery, 25% armed robbery and 9.7% homicide, confirming that heroin dependence drives acquisitive crime and, under certain conditions, violent crime as well. There are also some limitations to these findings. Bacciardi et al. (2012) rely primarily on secondary evidence and do not fully disentangle withdrawal, ASPD and polydrug use, which makes it difficult to isolate the exact causes of violence. Additionally, Rafaiee et al.’s (2013) study is cross-sectional and geographically limited to one Iranian prison, which may not reflect broader patterns of heroin-crime relationships across different cultural and legal contexts.

Overall, research shows that heroin dependency leads to measurable criminal activity. The United States National Institute of Justice found that “crime rates dropped to relatively low levels during periods when [users] had little or no narcotic use” (Gropper, 1985). In contrast, while users were actively addicted, their criminality was typically about 4-6 times higher (Gropper, 1985), demonstrating a straightforward correlation: as people get more addicted to heroin, they commit more crimes.

A Feedback Model of Heroin-Related Crime

Most research indicates that heroin-related criminality reflects the interaction of personal vulnerabilities, state-dependent hazards and economic pressures. Kang et al. (2024) and Reid et al. (2018) show that impulsivity increases risk-taking and short-horizon choices. Bacciardi et al. (2012) note that withdrawal elevates stress and weakens inhibitory control, raising the likelihood of offending. Among people with antisocial personality disorder, these vulnerabilities are stronger, which increases the tendency to break rules and, for some, resort to violence (Bacciardi et al., 2012; Rafaiee et al., 2013). To sustain use, many individuals engage in acquisitive offences, which in turn perpetuate cycles of dependence and crime (ONDCP, 2013; Pierce et al., 2017). This creates a feedback loop: impulsivity predisposes heroin initiation; ongoing use further undermines decision-making; withdrawal pressures drive acquisitive crime, which funds continued use and re-exposure to withdrawal. By integrating these factors, we can show why heroin is disproportionately associated with acquisitive crime and rarely with violence (ONDCP, 2013; Pierce et al., 2017).

Figure 3: A feedback model of heroin-related crime (conceptual model created by the authors, integrating findings from Bacciardi et al. (2012), Kang et al. (2024), ONDCP (2013), Pierce et al. (2017) and others).

Future longitudinal research should clarify whether impulsivity and ASPD are primarily predisposing traits or also a consequence of chronic heroin use (Kang et al., 2024; Pierce et al., 2017). When we look at how psychological problems, withdrawal symptoms and money pressures work together, we can see why heroin leads to crime in particular ways. This suggests treatment needs to address both the behavioural and biological sides of addiction.

There are a number of factors that contribute to heroin’s association with crime, as demonstrated by these findings. Neuropsychological impairment, withdrawal pressures and individual vulnerabilities create a distinctive criminogenic pathway. A more integrated perspective can strengthen our theoretical understanding of heroin’s role in offending. It also lays the groundwork for targeted interventions, which can address addiction from a biological and behavioural perspective.

Conclusion

The sections above provide a clear relationship between substance abuse and crime. Research shows that alcohol, methamphetamine and heroin each influence criminal behaviour through disruptions of the brain. Alcohol consumption affects the frontal lobe, hippocampus and thalamus. Damage in these parts of the brain lowers inhibitory control, increases an individual’s aggression and lowers the ability to regulate stress. Methamphetamine decreases levels of “white matter” and natural dopamine and serotonin levels in the brain, as well as worsening memory and impairing judgement. Due to these effects, methamphetamine users are less likely to remember the violent acts they committed and the resulting consequences. Heroin alters the prefrontal cortex and reward pathways, reducing self-control and increasing compulsivity. These disruptions in neuropsychological pathways worsen impulsivity, risk-taking and criminal activity. All together, the evidence shows how biological damage and psychological pressures work together to create patterns directly tying crime to substance use.

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