No full-text available
To read the full-text of this research,
you can request a copy directly from the authors.
Multiple Victimizations and Overdose Among Women With a History of Illicit Drug Use
Abstract
The experiences of violence and overdose are highly prevalent among women who use illicit drugs. This study sought to ascertain whether multiple victimizations during adulthood increase the frequency of women’s overdose. The sample comprised 218 women recruited at Philadelphia harm reduction sites during 2016–2017. Victimization was assessed as exposure to 16 types of adulthood violence. Three measures were constructed for multiple victimizations: continuous and categorical polyvictimization, and predominant violence domain. Negative binomial regression estimated the incidence rate ratio (IRR) of lifetime overdoses from multiple victimizations. Lifetime history of opioid use (88.6%) and drug injection (79.5%) were common. Among overdose survivors (68.5%), the median of lifetime overdoses was 3. The majority of participants (58.7%) were victims of predominantly sexual violence, 26.1% experienced predominantly physical abuse/assault, and 3.7% were victims of predominantly verbal aggression/coercive control. Participants reported a mean of seven violence types; the higher-score category of polyvictimization (9–16 violence types) comprised 41.7% of the total sample. In multivariable models, one-unit increase in continuous polyvictimization was associated with 4% higher overdose rates (IRR: 1.04, 95% confidence interval [CI]: [1.00, 1.08]). Compared to women who were not victimized (11.5%), those in the higher-score category of polyvictimization (IRR: 2.01; 95% CI: [1.06, 3.80]) and exposed to predominantly sexual violence (IRR: 2.10, 95% CI: [1.13, 3.91]) were expected to have higher overdose rates. Polyvictimization and sexual violence amplified the risk of repeated overdose among drug-involved women. Female overdose survivors need to be screened for exposure to multiple forms of violence, especially sexual violence. Findings underscore the need to scale-up victimization support and overdose prevention services for disenfranchised women.
... Identifying such drivers may thus better guide overdose prevention efforts. Emerging evidence suggests that experiences of violence by intimate partners and non-intimate partners, including police violence, may be contributing to the escalating rates of drug overdose deaths among women (Ataiants et al., 2020;El-Bassel et al., 2020). To our knowledge, however, no studies have examined the effects of different types of violence on non-fatal drug overdose among Black women despite their higher rates of exposures to all types of violence (Breiding et al., 2015;Ritchie, 2017). ...
... Two studies reported significant associations between experiencing violence and overdose in mixed gender samples of people who inject drugs (Braitstein et al., 2003;Lunze et al., 2016). A recent study of 218 women in harm reduction programs found that higher cumulative scores of lifetime polyvictimization experiences from intimate and non-intimate partners were associated with a higher risk of overdose (Ataiants et al., 2020). Another recent study of 400 sex workers who use drugs in Kazakhstan found that experience of lifetime severe physical violence were associated with greater odds of non-fatal drug overdose (El-Bassel et al., 2020). ...
... Researchers have suggested that the emotional trauma and physical pain from experiencing more severe violence and cumulative violence may trigger the misuse of drugs and overdose (Ataiants et al., 2020;El-Bassel et al., 2020). The relationship between adult experiences of violence and overdose may also be mediated by childhood physical and sexual abuse, which is a wellestablished predictor of experiencing IPV and sexual assault as an adult (Appel & Holden, 1998;Edleson, 1999), and has also been found to significantly increase risk for an overdose Lake et al., 2015). ...
Research has documented associations between all types of violence and substance misuse among Black women. However, research has yet to examine how different experiences of violence may be contributing to the surging epidemic of drug overdose among Black women. This study was conducted between 2015 and 2018 among 296 Black women who were mandated to community supervision programs (CSPs) in New York City (NYC). We used generalized linear modeling (GLM) to estimate associations of the adjusted relative risk (aRR) of experiencing a non-fatal overdose based on exposure to each type of violence after controlling for potentially confounding variables. Lifetime prevalence of a non-fatal drug overdose was 13.9% ( n = 41). Lifetime severe physical/sexual violence by a male intimate partner (prevalence rate = 61.8%, n = 181) was associated with an overdose (aRR = 3.41, 95%CI = 1.19, 9.73). Severe violence by a female partner (prevalence rate = 7.4%, n = 22) was also associated with an overdose (aRR = 2.61, 95%CI = 1.46, 4.65). Lifetime sexual violence by a non-intimate partner (prevalence rate: 29.1%, n = 86) was associated with an overdose (aRR = 2.23, 95%CI = 1.32, 3.77). Sexual abuse by police/CSP staff (prevalence rate: 14.9%, n = 44) was associated with an overdose (aRR = 2.29, 95%CI = 1.27, 4.12). For each increase in the number of types of violence experienced, there was a 27% increase in the risk for an overdose (aRR = 1.27, 95%CI = 1.14, 1.42). This study found high rates of multiple types of violence that are associated with drug overdose among this sample of Black women in CSPs. These findings highlight the urgent public health need to address violence associated with overdose in this population.
... Biological differences also contribute to decreased opioid tolerance among women and may result in an increased risk of overdose (Greenfield et al., 2010;Springer et al., 2020). Other overdose risk factors that are common among justice-involved women, specifically, include pervasive trauma and victimization histories, elevated levels of poverty, low social support, and a high prevalence of opioid and polysubstance use (Altekruse et al., 2020;Ataiants et al., 2022;Augsburger et al., 2022;Bunting et al., 2020;Kinner et al., 2012;Lynch et al., 2012;Scott et al., 2015;Springer et al., 2020;Tuchman, 2010;Yarborough et al., 2016). However, as mentioned, there remain gaps in our understanding of the vulnerabilities experienced by women both pre-and post-incarceration that increase their risk for overdose. ...
... Expanding upon earlier work demonstrating a correlation between adult victimization and overdose, the current study also highlights the risks associated with childhood victimization-a gap identified by Ataiants et al. (2022). This oversight in the current literature is particularly noteworthy concerning justice-involved women, who commonly report childhood victimization. ...
Background: Previous non-fatal overdose may increase risk of overdose fatality for women reentering the community following incarceration, but pre-incarceration overdose experiences are understudied. This study describes the prevalence and correlates of non-fatal overdose prior to jail among women with opioid use disorder (OUD). Methods: Women (N = 700) were randomly selected from eight Kentucky jails, screened for OUD, and interviewed as part of the NIDA-funded Kentucky Justice Community Opioid Innovation Network (JCOIN) trial. Descriptive statistics were used to examine women’s prior overdose experiences, while bivariate analyses and logistic regression were used to identify correlates of overdose in the 90 days prior to jail. Results: Analyses found that 55.4% of women had overdosed in their lifetime, and 21.4% overdosed in the 90 days prior to jail. Of those who overdosed in the 90 days prior to jail, heroin (80.7%) was the most-commonly used drug prior to overdose, 35.2% received emergency, medically-attended services post-overdose, and 92.4% were administered naloxone – primarily by acquaintances. Overdosing in the 90 days prior to jail was positively correlated with identifying as a sexual minority, being from an urban community, childhood victimization, as well as recent heroin, fentanyl, and injection drug use. Conclusions: Findings indicate that prior overdose is common among jailed women with OUD, and although naloxone was often administered, few women received medically-attended services post-overdose. Results highlight the importance of distributing naloxone to community members and women reentering the community from jail, and suggest additional research is needed to understand factors inhibiting medical care following an overdose.
... 144 Risk of relapse during the reentry period and the associated overdose risk may be further complicated by the vulnerabilities experienced by women both before, and following incarceration (eg, mental health problems, parenting-related stress, and history of victimization). 44,146,147 These vulnerabilities are an important consideration when connecting women to community care, and interventions that address these needs holistically are critical in ensuring positive reentry outcomes for women, including risk reduction of relapse and/or overdose. ...
... Relapse after incarceration-induced abstinence is associated with an exponential increase in overdose fatality. [161][162][163] Because women with SUD experience unique structural and social vulnerabilities that impact both relapse and overdose risk (eg, drug-involved romantic relationships, interpersonal violence, lifetime adverse experiences, poor mental health, parenting-related stress, and unequal gendered power 146,147,164,165 interventions that address these types of underlying factors are critical in having a long-term, sustainable impact on successful recovery among women. ...
While research on substance use disorder (SUD) treatment among justice-involved populations has grown in recent years, the majority of corrections-based SUD studies have predominantly included incarcerated men or men on community supervision. This review 1) highlights special considerations for incarcerated women that may serve as facilitating factors or barriers to SUD treatment; 2) describes selected evidence-based practices for women along the cascade of care for SUD including screening and assessment, treatment and intervention strategies, and referral to services during community re-entry; and 3) discusses conclusions and implications for SUD treatment for incarcerated women.
... Stigma and gender-based violence also create barriers to accessing healthcare, including harm reduction services [7,8]. Experiencing multiple types of violence, specifically sexual violence, has been shown to amplify the risk of overdose in women [9]. ...
Background
Research on women who inject drugs is scarce in low- and middle-income countries. Women experience unique harms such as sexism and sexual violence which translate into negative health outcomes. The present work aims to provide insight into the experiences of women who inject drugs at the US–Mexico border to identify social and health-related risk factors for overdose to guide harm reduction interventions across the Global South.
Methods
We recruited 25 women ≥ 18 years of age accessing harm reduction and sexual health services at a non-governmental harm reduction organization, “Verter”, in Mexicali, Mexico. We employed purposeful sampling to recruit women who inject drugs who met eligibility criteria. We collected quantitative survey data and in-depth interview data. Analyses of both data sources involved the examination of descriptive statistics and thematic analysis, respectively, and were guided by the syndemic and continuum of overdose risk frameworks.
Results
Survey data demonstrated reports of initiating injection drug use at a young age, experiencing homelessness, engaging in sex work, being rejected by family members, experiencing physical violence, injecting in public spaces, and experiencing repeated overdose events. Interview data provided evidence of stigma and discrimination toward women, a lack of safe spaces and support systems, risk of overdose-related harms, sexual violence, and the overall need for harm reduction services.
Conclusion
Women who inject drugs in Mexicali describe experiences of violence, overdose, and public injecting. Women are particularly vulnerable in the Mexicali context, as this area faces a noticeable lack of health and social services. Evidenced-based harm reduction strategies such as safe consumption sites and overdose prevention strategies (e.g., naloxone distribution and training) may benefit this population. Evidence from local organizations could help close the gap in service provision in low-resource settings like Mexico, where government action is almost nonexistent.
This study tests a theoretically informed model to understand why women who use opioids (WWUO) are at risk of rape while using drugs. Structured interviews were conducted with 168 WWUO. Three domains were hypothesized to increase risk: the sexually coercive context of drug use, women's social vulnerability, and drug use severity. Logistic regression examined the odds of being raped by domain. One-third of WWUO had been raped while using drugs. The sexually coercive context and social vulnerability domains significantly increased women's odds of being raped. Prevention efforts should target social and contextual factors.
Background: Reproductive health research among women who use drugs has focused on pregnancy prevention and perinatal/neonatal outcomes, but there have been few investigations of miscarriage and abortion, including prevalence and associated factors. Methods: Using cross-sectional data from a sample of non-pregnant women receiving harm reduction services in Philadelphia in 2016-2017 we examined lifetime miscarriage and abortion (n = 187). Separately for both outcomes, we used modified Poisson regression to estimate prevalence ratios (PR) and 95% confidence intervals (CI) for associations with each correlate. We also explored correlates of reporting both miscarriage and abortion. Results: Approximately 47% experienced miscarriage, 42% experienced abortion, and 18% experienced both. Miscarriage correlates included: prescription opioid misuse (e.g., OxyContin PR 1.82, 95% CI 1.23, 2.69); 40% increase in prevalence associated with housing instability, 50% increase with survival sex, and two-fold increase with arrest. Abortion correlates included: mental health (e.g., depression PR 2.09, 95% CI 1.18, 3.71), stimulant use (e.g., methamphetamine PR 1.83, 95% CI 1.22, 2.74), and drug injection (PR 1.76, 95% CI 1.03, 3.02); partner controlling access to people/possessions, physical and emotional violence; and a two-fold increase associated with survival sex and arrest. Experiencing both reproductive outcomes was correlated with mental health, opioid and simulant use, housing instability, survival sex, and arrest. Conclusion: Miscarriage and abortion was common among women with history of drug misuse suggesting a need for expanded access to family planning, medication-assisted therapy, and social support services, and for the integration of these with substance use services. Future research in longitudinal data is needed.
People with opioid use disorder (OUD) are vulnerable to negative health outcomes related to substance use and psychosocial issues, such as interpersonal trauma (IPT). Participants receiving buprenorphine completed a cross-sectional survey (July–September 2019). OUD outcomes were prospectively abstracted over a 28-week timeframe. More than a third reported recent IPT (40% women, 36% men). Sexual violence was more common among women than men ( p = .02). For women only, IPT was associated with substance use during follow-up (β = 20.72, 95% CI: 4.24, 37.21). It is important for public health strategies in the opioid crisis to address IPT using sex- and gender-informed approaches.
Intimate partner violence is common among people with opioid use disorder (OUD), but little research has focussed on identifying barriers survivors with OUD face when trying to leave an abusive relationship. Semi-structured interviews were conducted with 40 postpartum women with OUD. Interview questions were designed to identify barriers to help-seeking and facilitators and supports that have helped survivors make positive changes. Qualitative data were coded and analyzed, using a phenomenological approach to develop emerging themes. Most participants were white, 24–29 years old, single, unemployed, Medicaid insured, and used medications for OUD. All participants (n = 40, 100%) shared that a current or past partner physically, sexually, emotionally, or verbally abused them. Participants identified multiple barriers to help-seeking including abusive partner control of money and resources, fear of retaliatory violence, and concerns related to police and child welfare. Participants also described supports that helped them make positive changes, including being treated with care and support from domestic violence shelters and treatment programs. Finally, survivors offered suggestions for ways providers can better meet survivors’ needs. Clinicians and policymakers should prioritize overcoming multiple barriers to service access and engagement faced by survivors and their children.
Purpose of Review
Women with opioid use disorder (OUD) face unique challenges the moment they enter treatment. This narrative review focused on recent literature regarding sex- and gender-based issues that could affect treatment outcomes in women with OUD.
Recent Findings
Women respond differently to opioids based on hormonal factors, are more likely to present to treatment with mental health conditions, especially depression, and are more likely to have experienced trauma via intimate partner violence compared with men. Women also face stigma when entering OUD treatment, particularly if they have children.
Summary
Future research to improve OUD treatment outcomes in women should account for sex as a biological variable and gender as a social construct. Women have a fundamentally different experience than men during the course of OUD and upon treatment entry. Programs that address childcare/family support, mental health, and trauma are warranted for women with OUD.
Of the 70,237 drug overdose deaths in the United States in 2017, approximately two thirds (47,600) involved an opioid (1). In recent years, increases in opioid-involved overdose deaths have been driven primarily by deaths involving synthetic opioids other than methadone (hereafter referred to as synthetic opioids) (1). CDC analyzed changes in age-adjusted death rates from 2017 to 2018 involving all opioids and opioid subcategories* by demographic characteristics, county urbanization levels, U.S. Census region, and state. During 2018, a total of 67,367 drug overdose deaths occurred in the United States, a 4.1% decline from 2017; 46,802 (69.5%) involved an opioid (2). From 2017 to 2018, deaths involving all opioids, prescription opioids, and heroin decreased 2%, 13.5%, and 4.1%, respectively. However, deaths involving synthetic opioids increased 10%, likely driven by illicitly manufactured fentanyl (IMF), including fentanyl analogs (1,3). Efforts related to all opioids, particularly deaths involving synthetic opioids, should be strengthened to sustain and accelerate declines in opioid-involved deaths. Comprehensive surveillance and prevention measures are critical to reducing opioid-involved deaths, including continued surveillance of evolving drug use and overdose, polysubstance use, and the changing illicit drug market; naloxone distribution and outreach to groups at risk for IMF exposure; linkage to evidence-based treatment for persons with substance use disorders; and continued partnerships with public safety.
Introduction
Police violence against people who inject drugs (PWID) is common in Russia and associated with HIV risk behaviours. Sexual violence from police against women who use drugs has been reported anecdotally in Russia. This mixed-methods study aimed to evaluate sexual violence from police against women who inject drugs via quantitative assessment of its prevalence and HIV risk correlates, and through qualitative interviews with police, substance users and their providers in St. Petersburg, Russia.
Methods
Cross-sectional analyses with HIV-positive women who inject drugs (N=228) assessed the associations between sexual violence from police (i.e. having been forced to have sex with a police officer) and the following behaviours: current drug use, needle sharing and injection frequency using multiple regression models. We also conducted in-depth interviews with 23 key informants, including PWID, police, civil society organization workers, and other stakeholders, to explore qualitatively the phenomenon of sexual violence from police in Russia and strategies to address it. We analyzed qualitative data using content analysis.
Results
Approximately one in four women in our quantitative study (24.1%; 95% CI, 18.6%, 29.7%) reported sexual violence perpetrated by police. Affected women reported more transactional sex for drugs or money than those who were not; however, the majority of those reporting sexual violence from police were not involved in these forms of transactional sex. Sexual violence from police was not significantly associated with current drug use or needle sharing but with more frequent drug injections (adjusted incidence rate ratio 1.43, 95% CI 1.04, 1.95). Qualitative data suggested that sexual violence and coercion by police appear to be entrenched as a norm and are perceived insurmountable because of the seemingly absolute power of police. They systematically add to the risk environment of women who use drugs in Russia.
Conclusions
Sexual violence from police was common in this cohort of Russian HIV-positive women who inject drugs. Our analyses found more frequent injection drug use among those affected, suggesting that the phenomenon represents an underappreciated human rights and public health problem. Addressing sexual violence from police against women in Russia will require addressing structural factors, raising social awareness and instituting police trainings that protect vulnerable women from violence and prevent HIV transmission.
Drug and alcohol use have been associated with increased risk for sexual violence, but there is little research on sexual violence within the context of drug use among young adult opioid users. The current mixed-methods study explores young adult opioid users' sexual experiences in the context of their drug use. Forty-six New York City young adults (ages 18-32) who reported lifetime nonmedical use of prescription opioids (POs) completed in-depth, semistructured interviews, and 164 (ages 18-29) who reported heroin and/or nonmedical PO use in the past 30 days completed structured assessments that inquired about their drug use and sexual behavior and included questions specific to sexual violence. Participants reported frequent incidents of sexual violence experienced both personally and by their opioid using peers. Participants described sexual violence, including sexual assault, as occurring within a context characterized by victimization of users who were unconscious as a result of substance use, implicit and explicit exchanges of sex for drugs and/or money that increased risk for sexual violence, negative sexual perceptions ascribed to drug users, and participants' own internalized stigma. Recommendations to reduce sexual violence among young adult opioid users include education for users and service providers on the risk of involvement in sexual violence within drug using contexts and efforts to challenge perceptions of acceptability regarding sexual violence.
© The Author(s) 2015.
In this study, we used data from life histories of 424 non-incarcerated (n = 266) and incarcerated (n = 158) women to examine the extent to which women are exposed to multiple forms of victimization, including child abuse, intimate partner violence, sexual assault, and traumatic life events. We assessed the effects of polyvictimization (e.g., multiple victimizations) on women's health-related outcomes (e.g., attempted suicide, drug and alcohol problems) as well as whether the prevalence rates and effects of victimization were significantly different between the subsamples of women. Results indicate that incarcerated women experience significantly more victimization than non-incarcerated women, and while polyvictimization was associated with a higher likelihood of alcohol problems, drug problems, and attempted suicide among non-incarcerated women, it was only marginally associated with an increased likelihood of alcohol problems among incarcerated women. Finally, low levels of polyvictimization affected alcohol and drug problems among incarcerated and non-incarcerated women differently.
© The Author(s) 2015.
Non-fatal drug overdose is a major cause of morbidity among people who use drugs, although few studies have examined this risk among street-involved youth. We sought to determine the risk factors associated with non-fatal overdose among Canadian street-involved youth who reported illicit drug use.
Using data from a prospective cohort of street-involved youth in Vancouver, Canada, we identified youth without a history of overdose and employed Cox regression analyses to determine factors associated with time to non-fatal overdose between September 2005 and May 2012.
Among 615 participants, 98 (15.9%) reported a non-fatal overdose event during follow-up, resulting in an incidence density of 7.67 cases per 100 person-years. In multivariate Cox regression analyses, binge drug use (adjusted hazard ratio [AHR]=1.85; 95% confidence interval [CI]=1.20-2.84), non-injection crystal methamphetamine use (AHR=1.70; 95% CI=1.12-2.58), non-injection prescription opiate use (AHR=2.56; 95% CI=1.36-4.82), injection prescription opiate use (AHR=2.49; 95% CI=1.40-4.45) and injection heroin use (AHR=1.85; 95% CI=1.14-3.00) were positively associated with time to non-fatal overdose. Social, behavioural and demographic factors were not significantly associated with time to non-fatal overdose event.
Rates of non-fatal overdose were high among street-involved youth. Drug use patterns, in particular prescription opiate use, were associated with overdose. These findings underscore the importance of addiction treatment and prevention efforts aimed at reducing the risk of overdose among youth.
Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.
One of the most recent major shifts in focus of child maltreatment research has been the recognition of the interrelatedness of childhood victimisation experiences. The purpose of this paper is to compare two of the main frameworks that have been developed to better understand and measure this interrelatedness: multi-type maltreatment and polyvictimisation. This paper first compares multi-type maltreatment and polyvictimisation conceptually, outlining the history of the development of the two frameworks, the measurement tools used to operationalise them, and a selection of illustrative findings from some important studies in their respective histories. Second, the paper compares these frameworks empirically, using data from the Australian Temperament Project to explore their utility in identifying the long-term psychosocial outcomes associated with childhood adversity. The paper demonstrates the value of both the multi-type maltreatment and polyvictimisation frameworks, and suggests that both have different strengths that may make them preferable for particular forms of research.
Although qualitative research in the area of gender-responsive offending pathways has grown extensively, little quantitative work has been conducted. This study utilizes interview and survey data to assess various gender-responsive needs with an intake cohort of 313 women probationers. Using a path analytic approach, the study statistically supported three gendered pathways to women offenders' incarceration: (a) a pathway beginning with childhood victimization that contributed to historical and current forms of mental illness and substance abuse; (b) a relational pathway in which women's dysfunctional intimate relationships facilitated adult victimization, reductions in self-efficacy, and current mental illness and substance abuse; and (c) a social and human capital pathway in which women's challenges in the areas of education, family support, and self-efficacy, as well as relationship dysfunction, contributed to employment/financial difficulties and subsequent imprisonment. Support for such gendered pathways has implications for both criminological explanations of female offending and correctional interventions for women.
Violence against female sex workers (FSWs) can impede HIV prevention efforts and contravenes their human rights. We developed a multi-layered violence intervention targeting policy makers, secondary stakeholders (police, lawyers, media), and primary stakeholders (FSWs), as part of wider HIV prevention programming involving >60,000 FSWs in Karnataka state. This study examined if violence against FSWs is associated with reduced condom use and increased STI/HIV risk, and if addressing violence against FSWs within a large-scale HIV prevention program can reduce levels of violence against them.
FSWs were randomly selected to participate in polling booth surveys (PBS 2006-2008; short behavioural questionnaires administered anonymously) and integrated behavioural-biological assessments (IBBAs 2005-2009; administered face-to-face).
3,852 FSWs participated in the IBBAs and 7,638 FSWs participated in the PBS. Overall, 11.0% of FSWs in the IBBAs and 26.4% of FSWs in the PBS reported being beaten or raped in the past year. FSWs who reported violence in the past year were significantly less likely to report condom use with clients (zero unprotected sex acts in previous month, 55.4% vs. 75.5%, adjusted odds ratio (AOR) 0.4, 95% confidence interval (CI) 0.3 to 0.5, p < 0.001); to have accessed the HIV intervention program (ever contacted by peer educator, 84.9% vs. 89.6%, AOR 0.7, 95% CI 0.4 to 1.0, p = 0.04); or to have ever visited the project sexual health clinic (59.0% vs. 68.1%, AOR 0.7, 95% CI 0.6 to 1.0, p = 0.02); and were significantly more likely to be infected with gonorrhea (5.0% vs. 2.6%, AOR 1.9, 95% CI 1.1 to 3.3, p = 0.02). By the follow-up surveys, significant reductions were seen in the proportions of FSWs reporting violence compared with baseline (IBBA 13.0% vs. 9.0%, AOR 0.7, 95% CI 0.5 to 0.9 p = 0.01; PBS 27.3% vs. 18.9%, crude OR 0.5, 95% CI 0.4 to 0.5, p < 0.001).
This program demonstrates that a structural approach to addressing violence can be effectively delivered at scale. Addressing violence against FSWs is important for the success of HIV prevention programs, and for protecting their basic human rights.
Intimate partner violence victimization was examined in men (N = 4,459) and women (N = 1,774) entering substance use disorder treatment. Nearly 1 in 2 women and 1 in 10 men reported lifetime victimization by an intimate partner. Entering treatment for alcohol, as compared
to drug abuse and history of childhood abuse, were each associated with intimate partner violence victimization. Victimization by an intimate partner was also associated with mental health problems, including depression, anxiety, and attempted suicide. Although victimization was linked to
physical health problems, the nature of these problems varied by gender. Women and men with a history of intimate partner victimization present to substance use disorder treatment with a complex array of mental and physical health problems.
To examine the prevalence and structural correlates of gender based violence against female sex workers in an environment of criminalised prostitution.
Prospective observational study.
Vancouver, Canada during 2006-8.
Female sex workers 14 years of age or older (inclusive of transgender women) who used illicit drugs (excluding marijuana) and engaged in street level sex work.
Self reported gender based violence.
Of 267 female sex workers invited to participate, 251 women returned to the study office and consented to participate (response rate of 94%). Analyses were based on 237 female sex workers who completed a baseline visit and at least one follow-up visit. Of these 237 female sex workers, 57% experienced gender based violence over an 18 month follow-up period. In multivariate models adjusted for individual and interpersonal risk practices, the following structural factors were independently correlated with violence against female sex workers: homelessness (adjusted odds ratio for physical violence (aOR(physicalviolence)) 2.14, 95% confidence interval 1.34 to 3.43; adjusted odds ratio for rape (aOR(rape)) 1.73, 1.09 to 3.12); inability to access drug treatment (adjusted odds ratio for client violence (aOR(clientviolence)) 2.13, 1.26 to 3.62; aOR(physicalviolence) 1.96, 1.03 to 3.43); servicing clients in cars or public spaces (aOR(clientviolence) 1.50, 1.08 to 2.57); prior assault by police (aOR(clientviolence) 3.45, 1.98 to 6.02; aOR(rape) 2.61, 1.32 to 5.16); confiscation of drug use paraphernalia by police without arrest (aOR(physicalviolence) 1.50, 1.02 to 2.41); and moving working areas away from main streets owing to policing (aOR(clientviolence) 2.13, 1.26 to 3.62).
Our results demonstrate an alarming prevalence of gender based violence against female sex workers. The structural factors of criminalisation, homelessness, and poor availability of drug treatment independently correlated with gender based violence against street based female sex workers. Socio-legal policy reforms, improved access to housing and drug treatment, and scale up of violence prevention efforts, including police-sex worker partnerships, will be crucial to stemming violence against female sex workers.
Two studies examined the relationships among polyvictimization (i.e., high cumulative levels of victimization), six categories of childhood victimization (i.e., property crime, physical assault, peer/sibling, witnessed/indirect, sexual, and child maltreatment), and current psychological symptomatology in college females. Results indicated that exposure to multiple types of childhood victimization is common. Regression analyses revealed that polyvictimization accounted for a significant proportion of variability in scores for psychological distress beyond that accounted for by any victimization category alone. Moreover, the six categories separately accounted for little to no variability beyond that accounted for by polyvictimization. Finally, polyvictimization accounted for a significant proportion of variability in scores for psychological distress, beyond that already accounted for through the simultaneous entry of all six categories of victimization. Findings reiterate the importance for clinicians and researchers to comprehensively assess multiple categories of childhood victimization and polyvictimization and provide preliminary evidence that the total number of lifetime victimizations is at least as important, if not more important, than individual categories of victimization in predicting psychological distress.
This study examines various contexts in which drug-related activities may be linked with intimate partner violence among women in methadone treatment. We conducted 14 focus groups with 68 predominantly Latina and African American women, who reported recent partner abuse. Guided by Goldstein's tripartite model, gender theory, and trauma theory, our inquiry explored how partner violence may be related to psychopharmacological effects of drug use and to conflicts over procuring and splitting drugs. We also examined whether women used drugs to cope with the violence. Across the focus groups, women reported that their low social status and perceived sexual availability as "drug-using women," their partner's substance use, their own verbal aggression under the influence of crack and alcohol, and conflicts over procuring and splitting drugs played a role in their victimization. The findings further suggest that conflicts over gender role expectations interact with drug-related activities, increasing the likelihood of a violent outcome.
A theoretical understanding of the gendered contours of structural, everyday and symbolic violence suggests that young addicted women are particularly vulnerable to the infectious diseases caused by injection drug use-especially hepatitis C. Participant-observation fieldwork among heroin and speed addicts in San Francisco's Haight Ashbury neighborhood reveals that extreme levels of violence against women are normalized in the common sense of street-youth drug culture. Physical, sexual and emotional violence, as well as the pragmatics of income generation, including drug and resource sharing in the moral economy of street addicts, oblige most young homeless women to enter into relationships with older men. These relationships are usually abusive and economically parasitical to the women. Sexual objectification and a patriarchal romantic discourse of love and moral worth leads to the misrecognition of gender power inequities by both the men and women who are embroiled in them, as well as by many of the public services and research projects designed to help or control substance abusers. Despite deep epistemological, theoretical and logistical gulfs between quantitative and qualitative methods, applied public health research and the interventions they inform can benefit from the insights provided by a theoretical and cross-methodological focus on how social power contexts shape the spread of infectious disease and promote disproportional levels of social suffering in vulnerable populations.
Meta-analyses of studies yielding sex-specific risk of potentially traumatic events (PTEs) and posttraumatic stress disorder (PTSD) indicated that female participants were more likely than male participants to meet criteria for PTSD, although they were less likely to experience PTEs. Female participants were more likely than male participants to experience sexual assault and child sexual abuse, but less likely to experience accidents, nonsexual assaults, witnessing death or injury, disaster or fire, and combat or war. Among victims of specific PTEs (excluding sexual assault or abuse), female participants exhibited greater PTSD. Thus, sex differences in risk of exposure to particular types of PTE can only partially account for the differential PTSD risk in male and female participants.
Young injection drug users (IDUs) may be at increased risk of premature mortality due to the health risks associated with injection drug use including overdoses and infections. However, there has been little research conducted on mortality causes, rates and associations among this population. We undertook this study to investigate patterns of premature mortality, prior to age 30 years, among young IDUs.
Since 1996, 572 young (< or = 29 years) IDUs have been enrolled in the Vancouver Injection Drug Users Study (VIDUS). Semi-annually, participants have completed an interviewer-administered questionnaire and have undergone serologic testing for HIV and hepatitis C (HCV). Mortality data have been continually updated through linkages with the Provincial Coroner's Office. Crude and age-specific mortality rates, standardized mortality ratios, and life expectancy measures were calculated using person-time methods. Predictors of mortality were identified using Cox regression analyses.
Twenty-two participants died prior to age 30 years during the follow-up period for an overall crude mortality rate of 1,368 per 100,000 person-years. Overall, young IDUs were 16.4 times (95% confidence interval [CI]; 9.1-27.1) more likely to die; young women IDUs were 54.1 times (95%CI; 29.6-90.8) and young men IDUs were 12.9 times (95%CI; 5.5, 25.3) more likely to die when compared to the Canadian non-IDU population of the same age. The leading observed cause of death among females was: homicide (N = 9); and among males: suicide (N = 3) and overdose (N = 3). In Cox regression analyses, factors associated with mortality were, HIV infection (Hazard Ratio [HR]: 4.55; CI: 1.92-10.80) and sex work (HR: 2.76; CI: 1.16-6.56).
Premature mortality was 13 and 54 times higher among young men and women who use injection drugs in Vancouver than among the general population in Canada. The majority of deaths among the women were attributable to homicide, suggesting that interventions should occur not only through harm reduction services but also through structural interventions at the legal and policy level.
To determine annual patterns and correlates of nonfatal heroin overdose across 3 years, data were analyzed on 387 heroin users recruited for the Australian Treatment Outcome Study (ATOS), interviewed at 12, 24, and 36 months. A heroin overdose across follow-up was reported by 18.6%, and naloxone had been administered to 11.9%. Annual rates of overdose declined between baseline and 12 months and then remained stable. Previous overdose experience was strongly related to subsequent overdose. Those with a history of overdose before ATOS were significantly more likely to overdose during the study period. In particular, there was a strong association between overdose experience in any 1 year and increased overdose risk in the subsequent year. This is the first study to examine long-term annual trends in nonfatal heroin overdose. While overdose rates declined after extensive treatment, substantial proportions continued to overdose in each year, and this was strongly associated with overdose history.
Background:
People who inject drugs (PWID) are at an elevated risk of fatal overdose in the first year after experiencing a non-fatal event. Such non-fatal events may also result in overdose-related sequelae, ranging from physical injury to paralysis. Given variation in drug markets and treatment availability across countries and regions, we may see similar variations in non-fatal overdose prevalence. Monitoring non-fatal overdose prevalence among PWID is essential for informing treatment intervention efforts, and thus our review aims to estimate the global, regional, and national prevalence of non-fatal overdose, and determine characteristics associated with experiencing such an event.
Methods:
We conducted a systematic review and meta-analyses to estimate country, regional, and global estimates of recent and lifetime non-fatal overdose prevalence among PWID. Using meta-regression analyses we also determined associations between sample characteristics and non-fatal overdose prevalence.
Results:
An estimated 3.2 (1.8-5.2) million PWID have experienced at least one overdose in the previous year. Among PWID, 20.5% (15.0-26.1%) and 41.5% (34.6-48.4%) had experienced a non-fatal event in the previous 12 months and lifetime respectively. Frequent injecting was strongly associated with PWID reporting recent and lifetime non-fatal overdose. Estimates of recent non-fatal overdose were particularly high in Asia and North America.
Conclusion:
Around one in five PWID are at an elevated risk of fatally overdosing every year, however there is substantial geographical variation. In countries with higher rates of non-fatal overdose there is need to introduce or mainstream overdose prevention strategies such as opioid agonist treatment and naloxone administration training programs.
Introduction:
Adverse childhood experiences are associated with the development of substance use disorders. With opioid use disorder, a growing concern in the United States, we were interested in examining the relationship between adverse experiences and three landmarks of opioid use: age of opioid initiation, injection drug use, and lifetime overdose.
Methods:
Between May and December 2015, we interviewed consecutive persons seeking inpatient opioid detoxification. Participants were asked about age of opioid initiation, last month injection drug use, and lifetime history of overdose, and completed the ten-item Adverse Childhood Experience (ACE) questionnaire.
Results:
Participants (n=457) averaged 32.2 (±8.64) years of age, 71.3% were male, and 82.5% were non-Hispanic White. The mean score on the ACE scale was 3.64 (±2.75). Mean age at time of initiating opioid use was 21.7 (±7.1) years, 68.7% had injected drugs within the past month, and 39.0% had overdosed. After adjusting for age, gender, and ethnicity, the ACE score was inversely associated with age of initiating opioid use (b=-0.50, 95% CI -0.70; -0.29, p<.001), and positively associated with recent injection drug use (OR=1.11, 95% CI 1.02; 1.20, p=0.014) and the likelihood of experiencing an overdose (OR=1.10, 95% CI 1.02; 1.20, p=0.015) in a graded dose response manner.
Conclusion:
Greater adverse childhood experiences are associated with three landmarks of opioid use risk. ACE screening may be useful in identifying high-risk subsets of opioid-using populations.
Objectives:
To determine the prevalence and patterns of polysubstance use among US reproductive-aged women who use opioids for nonmedical purposes.
Methods:
We used the National Survey of Drug Use and Health (2005-2014) data on female respondents aged 18 to 44 years reporting nonmedical opioid use in the past 30 days (unweighted n = 4498). We categorized patterns of polysubstance use in the past 30 days, including cigarettes, binge drinking, and other legal and illicit substances and reported prevalence adjusted for age, race/ethnicity, and educational attainment.
Results:
Of all women with nonmedical opioid use, 11% reported only opioid use. Polysubstance use was highest in non-Hispanic White women and women with lower educational attainment. The most frequently used other substances among women using opioids nonmedically were cigarettes (56.2% smoked > 5 cigarettes per day), binge drinking (49.7%), and marijuana (32.4%). Polysubstance use was similarly prevalent among pregnant women with nonmedical opioid use.
Conclusions:
Polysubstance use is highly prevalent among US reproductive-aged women reporting nonmedical opioid use. Public Health Implications. Interventions are needed that address concurrent use of multiple substances. (Am J Public Health. Published online ahead of print June 22, 2017: e1-e3. doi:10.2105/AJPH.2017.303825).
Background and aims:
The time post-release from prison involves elevated mortality, especially overdose deaths. Variations in overdose mortality both by time since release from prison and time of release has not been sufficiently investigated. Our aims were to estimate and compare overdose death rates at time intervals after prison release and to estimate the effect on overdose death rates over calendar time.
Design, setting, participants, measurements:
This 15-year cohort study includes all persons (n= 91,090) released from prison (01.01.2000 to 31.12.2014) obtained from the Norwegian prison registry, linked to the Norwegian Cause of Death Registry (2000-2014). All-cause and cause-specific mortality were examined during different time-periods following release: first week, second week, 3-4 weeks and 2-6 months, and by three different time intervals of release. We calculated crude mortality rates (CMRs) per 1000 PY and estimated incidence rate ratios (IRR) by Poisson regression analysis adjusting for time intervals after prison release, release periods and time spent in prison.
Findings:
Overdose deaths accounted for 85% (n=123) of all deaths during the first week following release (n=145), with a peak during the two days immediately following release. Compared with week 1, the risk of overdose death was more than halved during week 2 (IRR 0.43; 95% CI, 0.31-0.59) and reduced to one-fifth in weeks 3-4 (IRR 0.22; 95% CI, 0.16-0.31). The risk of overdose mortality during the first 6 months post-release was almost twofold higher in 2000-2004 compared with 2005-2009 (IRR 0.53; 95% CI, 0.43-0.65) and 2010-2014 (IRR 0.47; 95% CI, 0.37-0.59). The risk of overdose death was highest for those incarcerated for 3-12 months compared with those who were incarcerated for shorter or longer periods, and recidivism was associated with risk of overdose death.
Conclusions:
There is an elevated risk of death from drug overdose among people released from Norwegian prisons, peaking in the first week. The risk has reduced since 2000-2004 but is greatest for those serving 3-12 months compared with shorter or longer periods.
The aims of the present study were first to identify discrete patterns of childhood victimization experiences including crime, child maltreatment, peer/sibling victimization, sexual violence, and witnessing violence among adult trauma victims using latent class analysis; second, to examine the association between class-membership and suicidal behavior, and third to investigate the differential role of dispositional anger on the association between class-membership and suicidal behavior. We hypothesized that those classes with accumulating exposure to different types of childhood victimization (e.g., poly-victimization) would endorse higher suicidal behavior, than the other less severe classes, and those in the most severe class with higher anger trait would have stronger association with suicidal behavior. Respondents were 346 adults (N = 346; Mage = 35.0 years; 55.9% female) who had experienced a lifetime traumatic event. Sixty four percent had experienced poly-victimization (four or more victimization experiences) and 38.8% met the cut-off score for suicidal behavior. Three distinct classes emerged namely, the Least victimization (Class 1), the Predominantly crime and sibling/peer victimization (Class 2), and the Poly-victimization (Class 3) classes. Regression analysis controlling for age and gender indicated that only the main effect of anger was significantly associated with suicidal behavior. The interaction term suggested that those in the Poly-victimization class were higher on suicidal behavior as a result of a stronger association between anger and suicidal behavior in contrast to the association found in Class 2. Clinical implications of findings entail imparting anger management skills to facilitate wellbeing among adult with childhood poly-victimization experiences.
This study examined the relationship between different forms of childhood violence (emotional, physical, and sexual) and these same forms of violence in adulthood, using a cross-sectional baseline survey of 298 homeless and unstably housed women in San Francisco, California. We also examined other related factors, including mental illnesses diagnosis, sex exchange, jail time, HIV status, and sociodemographic information. Regression analysis indicated that although several of these factors were associated with experiences of violence as an adult, specific types of child violence (e.g., sexual violence) predicted instances of that same type of violence as an adult but not necessarily other types. Thus, risk of adult violence among low-income women may be better predicted and addressed through histories of same-type childhood violence, despite years of intervening exposures and stressors.
Objectives:
To examine the relationship between non-fatal overdose and risk of subsequent fatal overdose.
Methods:
We assessed risk factors for overdose death among two prospective cohorts of persons who inject drugs (PWID) in Vancouver, Canada. Extended Cox regression was used to examine if reports of non-fatal overdose were associated with the time to fatal overdose while adjusting for other behavioral, social and structural confounders.
Results:
Between May, 1996 and December, 2011, 2317 individuals were followed for a median of 60.8 months. In total, 134 fatal overdose deaths were identified for an incidence density of 8.94 (95% confidence interval [CI]: 7.55-10.59) deaths per 1000 person-years. During the study period there were 1795 reports of non-fatal overdose. In a multivariate model, recent non-fatal overdose was independently associated with the time to overdose mortality (adjusted hazard ratio [AHR]=1.95; 95% CI: 1.17-3.27). As well, there was a dose response effect of increasing cumulative reports of non-fatal overdose on subsequent fatal overdose.
Conclusion:
Reports of recent non-fatal overdose were independently associated with subsequent overdose mortality in a dose-response relationship. These findings suggest that individuals reporting recent non-fatal overdose should be engaged with intensive overdose prevention interventions.
In the present study, we sought to identify rates, causes, and predictors of death among male and female injection drug users (IDUs) in Vancouver, British Columbia, Canada, during a period of expanded public health interventions. Data from prospective cohorts of IDUs in Vancouver were linked to the provincial database of vital statistics to ascertain rates and causes of death between 1996 and 2011. Mortality rates were analyzed using Poisson regression and indirect standardization. Predictors of mortality were identified using multivariable Cox regression models stratified by sex. Among the 2,317 participants, 794 (34.3%) of whom were women, there were 483 deaths during follow-up, with a rate of 32.1 (95% confidence interval (CI): 29.3, 35.0) deaths per 1,000 person-years. Standardized mortality ratios were 7.28 (95% CI: 6.50, 8.14) for men and 15.56 (95% CI: 13.31, 18.07) for women. During the study period, mortality rates related to infection with human immunodeficiency virus (HIV) declined among men but remained stable among women. In multivariable analyses, HIV seropositivity was independently associated with mortality in both sexes (all P < 0.05). The excess mortality burden among IDUs in our cohorts was primarily attributable to HIV infection; compared with men, women remained at higher risk of HIV-related mortality, indicating a need for sex-specific interventions to reduce mortality among female IDUs in this setting.
Recently, use of prescription opioids (POs) has increased; non-medical PO (NMPO) use is linked to overdose. NMPO use is common among individuals prescribed opioids for pain, and those in substance use disorder (SUD) treatment with pain could be at increased risk for unintentional overdose due to NMPO use. We examined associations between pain, NMPO use, and overdose among SUD treatment patients.
Among 342 patients at a residential SUD treatment center, logistic regression examined the association of overdose with pain, adjusting for substance use, suicide attempts, and demographics.
Pain was positively related to NMPO use. Heroin use, suicide attempts, pain, and NMPO use were positively associated with overdose; but NMPO use attenuated the pain-overdose relationship.
The relationship between pain and overdose among substance users may be, in part, explained by the association between pain and heavy NMPO use. (Am J Addict 2014;23:41-47).
Chinese translation
Among former prisoners, a high rate of death has been documented in the early postrelease period, particularly from drug-related causes. Little is known about risk factors and trends in postrelease mortality in the past decade, especially given general population increases in overdose deaths from pharmaceutical opioids.
To determine postrelease mortality between 1999 and 2009; cause-specific mortality rates; and whether sex, calendar year, and custody factors were risk factors for all-cause, overdose, and opioid-related deaths.
Cohort study.
Prison system of the Washington State Department of Corrections.
76 208 persons released from prison.
Identities were linked probabilistically to the National Death Index to identify deaths and causes of death, and mortality rates were calculated. Cox proportional hazards regression estimated the effect of age, sex, race or ethnicity, whether the incarceration resulted from a violation of terms of the person's community supervision, length of incarceration, release type, and calendar year on the hazard ratio (HR) for death.
The all-cause mortality rate was 737 per 100 000 person-years (95% CI, 708 to 766) (n = 2462 deaths). Opioids were involved in 14.8% of all deaths. Overdose was the leading cause of death (167 per 100 000 person-years [CI, 153 to 181]), and overdose deaths in former prisoners accounted for 8.3% of the overdose deaths among persons aged 15 to 84 years in Washington from 2000 to 2009. Women were at increased risk for overdose (HR, 1.38 [CI, 1.12 to 1.69]) and opioid-related deaths (HR, 1.39 [CI, 1.09 to 1.79]).
The study was done in only 1 state.
Innovation is needed to reduce the risk for overdose among former prisoners.
National Institute on Drug Abuse and the Robert Wood Johnson Foundation.
Cross-sectional studies have shown that chronic musculoskeletal pain and somatic symptoms are frequently reported by sexual assault (SA) survivors; however, prospective studies examining pain and somatic symptoms in the months after SA have not been performed.
Women SA survivors 18 years of age or older who presented for care within 48 h of SA were recruited. Pain in eight body regions (head and face, neck, breast, arms, abdomen, back, genital and pelvic, and legs) and 21 common somatic symptoms (e.g., headache, nausea, insomnia, persistent fatigue) were assessed (0-10 numeric rating scale in each body region) at the time of presentation, 1-week, 6-week and 3-month interview. Post-traumatic stress disorder (PTSD) symptoms were assessed at the 6-week and 3-month interview.
Clinically significant new or worsening pain (CSNWP) symptoms were common among study participants 6 weeks after SA [43/74, 58% (95% CI, 47-69%)] and 3 months after SA [40/67, 60% (95% CI, 48-71%)] and generally occurred in regions not experiencing trauma. Women SA survivors also experienced an increased burden of many common somatic symptoms: 8/21 (38%) and 11/21 (52%) common somatic symptoms showed a significant increase in severity 6 weeks and 3 months after SA, respectively. Correlations between PTSD, CSNWP and somatic symptoms were only low to moderate, suggesting that these outcomes are distinct.
New and/or clinically worsening pain and somatic symptoms, lasting at least 3 months, are sequelae of SA. Further studies investigating pain and somatic symptoms after SA are needed.
Background:
Homeless persons experience excess mortality, but US-based studies on this topic are outdated or lack information about causes of death. To our knowledge, no studies have examined shifts in causes of death for this population over time.
Methods:
We assessed all-cause and cause-specific mortality rates in a cohort of 28 033 adults 18 years or older who were seen at Boston Health Care for the Homeless Program from January 1, 2003, through December 31, 2008. Deaths were identified through probabilistic linkage to the Massachusetts death occurrence files. We compared mortality rates in this cohort with rates in the 2003-2008 Massachusetts population and a 1988-1993 cohort of homeless adults in Boston using standardized rate ratios with 95% confidence intervals.
Results:
A total of 1302 deaths occurred during 90 450 person-years of observation. Drug overdose (n = 219), cancer (n = 206), and heart disease (n = 203) were the major causes of death. Drug overdose accounted for one-third of deaths among adults younger than 45 years. Opioids were implicated in 81% of overdose deaths. Mortality rates were higher among whites than nonwhites. Compared with Massachusetts adults, mortality disparities were most pronounced among younger individuals, with rates about 9-fold higher in 25- to 44-year-olds and 4.5-fold higher in 45- to 64-year-olds. In comparison with 1988-1993 rates, reductions in deaths from human immunodeficiency virus (HIV) were offset by 3- and 2-fold increases in deaths owing to drug overdose and psychoactive substance use disorders, resulting in no significant difference in overall mortality.
Conclusions:
The all-cause mortality rate among homeless adults in Boston remains high and unchanged since 1988 to 1993 despite a major interim expansion in clinical services. Drug overdose has replaced HIV as the emerging epidemic. Interventions to reduce mortality in this population should include behavioral health integration into primary medical care, public health initiatives to prevent and reverse drug overdose, and social policy measures to end homelessness.
This paper aimed to determine whether non-fatal opioid overdose and suicide attempts are distinct behaviours by examining the histories of 1500 opioid-dependent individuals. This paper utilised data collected as part of a large retrospective case-control study. Unintentional non-fatal opioid overdoses were more common than suicide attempts (58% vs. 32%). Overall, the correlates associated with a history of attempted suicide only and non-fatal opioid overdose only were different. Drug-related risk behaviours (including high impulsivity, injection of opioids, sedative dependence) were associated with non-fatal opioid overdose; and a history of mental disorders (depression, anxiety disorder, and screening positive for borderline personality disorder (BPD+) were associated with suicide attempts. Additionally, those who reported a history of both behaviours had a more severe clinical profile including excessive drug use, psychological disorders and childhood trauma. The study concluded that non-fatal opioid overdose and attempted suicide are distinct clinically significant problems that require different approaches for prevention. Additionally, if both behaviours are reported a thorough assessment of underlying comorbid problems should be initiated by treatment services.
Release from prison is associated with a markedly increased risk of both fatal and non-fatal drug overdose, yet the risk factors for overdose in recently released prisoners are poorly understood. The aim of this study was to identify risk and protective factors for non-fatal overdose (NFOD) among a cohort of illicit drug users in Vancouver, Canada, according to recent incarceration.
Prospective cohort of 2515 community-recruited illicit drug users in Vancouver, Canada, followed from 1996 to 2010. We examined factors associated with NFOD in the past six months separately among those who did and did not also report incarceration in the last six months.
One third of participants (n=829, 33.0%) reported at least one recent NFOD. Among those recently incarcerated, risk factors independently and positively associated with NFOD included daily use of heroin, benzodiazepines, cocaine or methamphetamine, binge drug use, public injecting and previous NFOD. Older age, methadone maintenance treatment and HIV seropositivity were protective against NFOD. A similar set of risk factors was identified among those who had not been incarcerated recently.
Among this cohort, and irrespective of recent incarceration, NFOD was associated with a range of modifiable risk factors including more frequent and riskier patterns of drug use. Not all ex-prisoners are at equal risk of overdose and there remains an urgent need to develop and implement evidence-based preventive interventions, targeting those with modifiable risk factors in this high risk group.
There are some 60,000 vacant properties in the city of Philadelphia, 30,000 of which are abandoned row houses. In the neighbourhood of Kensington, street-level entrepreneurs have reconfigured hundreds of former working-class row homes to produce the Philadelphia recovery house movement: an extra-legal poverty survival strategy for addicts and alcoholics located in the city's poorest and most heavily blighted zones. The purpose of this paper is to explore, ethnographically, the ways in which informal poverty survival mechanisms articulate with the restructuring of the contemporary welfare state and the broader political economy of Philadelphia. It is argued that recovery house networks accommodate an interrelated set of political rationalities animated not only by retrenchment and the churning of welfare bodies, but also by the agency of informal operators and the politics of self-help. Working as an alternative and partially vestigial boundary institution or buffer zone to formal regimes of governance, the recovery house movement reflects the ‘other story’ of the new urban politics in Philadelphia.
To examine mortality rates and causes of death among a cohort of substance-using mothers and to identify risk factors that predict mortality.
This is a prospective study of a cohort of 4447 substance-using mothers (pregnant or parenting) who were enrolled during 2000-02 in 40 drug abuse treatment programs across California.
All mothers were assessed at baseline using the Addiction Severity Index. Mortality data were obtained from the National Death Index and causes of death were coded using ICD-10. Standardized mortality ratios (SMR) were calculated relative to women in the general population adjusted for age. Proportional hazard (Cox) regression was used to identify risk factors predicting death.
At the end of 2010, 194 deaths were confirmed, corresponding to a crude mortality rate of 4.47 per 1000 person-years and SMR of 8.4 (95% confidence interval: 7.2-9.6). Drug overdose (28.8%), cardiovascular disease (10%), and alcohol or drug disorders (8.9%) were the leading causes of death. Baseline factors associated with higher mortality included older age, being white (relative to African American or Hispanic), heroin, alcohol, cocaine or marijuana (relative to methamphetamine) as the primary drug problem, drug injection and greater severity of employment, medical/health and psychiatric problems.
Substance-using mothers have 8.4 times the mortality than that observed among US women of similar age. Greater severity of employment, medical/health and psychiatric problems contributed to the elevated mortality.
Suicide attempts and non-fatal overdoses are both associated with substance use. The aim of the present study was to examine correlates of suicide attempts and non-fatal overdoses simultaneously among individuals seeking addictions treatment.
A large U.S. national sample of individuals entering addictions treatment participated in a cross-sectional survey (n=5892). Multinomial logistic regression modeling tested the adjusted associations of violence, injection drug use, specific substances, and depressive symptoms with a four-category outcome variable based on prior histories of suicide attempt and non-fatal overdose (neither, suicide attempt only, overdose only, both), adjusting for demographic and treatment characteristics.
Sexual and physical victimization was associated with suicide attempts with or without overdoses (ORs 1.25-2.84), while perpetrating violence was associated with having experienced either or both outcomes (ORs 1.25-1.56). Depressive symptoms had a stronger association with suicide attempts (OR=3.05) than overdoses (OR=1.29). Injection drug use was associated with overdoses with or without suicide attempts (ORs 2.65-3.22). Individuals seeking treatment for marijuana use were less likely have overdosed or attempted suicide (ORs 0.39-0.67), while individuals seeking treatment for heroin use were more likely to have overdosed (OR=1.46). Seeking treatment for use of more than one substance was associated with overdose and overdose and suicide attempt (ORs 1.58-2.51), but not suicide attempt alone.
The present findings indicate that suicide and overdose are connected yet distinct problems. Individuals who have had a history of both may be a group with particularly poor psychological functioning as well as more severe drug-related problems.
Fatal overdoses involving prescription opioids have increased significantly in recent years in the United States--especially in rural areas. However, there are scant data about non-fatal overdose among rural drug users. The purpose of this study is to examine the prevalence and correlates of non-fatal overdose and witnessed overdose among rural Appalachian drug users.
Rural drug users were participants in a longitudinal study of social networks and HIV transmission. An interviewer-administered questionnaire elicited information in the following domains: sociodemographic characteristics, drug use (including lifetime overdose and witnessed overdose), psychiatric disorders, HIV risk behaviors and social networks (support, drug and sex networks). Negative binomial regression was used to model the number of lifetime overdoses and witnessed overdoses.
Of the 400 participants, 28% had ever experienced a non-fatal overdose, while 58.2% had ever witnessed an overdose (fatal or non-fatal). Factors independently associated with a greater number of overdoses included having ever been in drug treatment, past 30-day injection of prescription opioids, meeting the criteria for post-traumatic stress disorder and/or antisocial personality disorder and having more members in one's support network.
Rural drug users with history of overdose were more likely to have injected with prescription opioids--which is different from urban heroin users. However, the remaining correlates of non-fatal overdose among this cohort of rural drug users were similar to those of urban heroin users, which suggests current overdose prevention strategies employed in urban settings may be effective in preventing fatal overdose in this population.
Study aims were to examine the relations between multiple forms of childhood maltreatment (CM) and adult violent victimization (AVV) and to explore other significant covariates of the relations between CM and AVV. Data were collected from women (n = 477) who participated in two longitudinal studies in the Maternal Health Practices and Child Development Project. Women with a history of CM were more than twice as likely to experience AVV as women with no history of CM. Those who experienced one or two forms of CM were significantly more likely to report any AVV compared to women with no CM. The relationship between CM and AVV remained significant after controlling for illicit drug use at baseline. Among low-income women, a history of CM exposure increased the risk of AVV. Having had any CM exposure was more important that the specific form or combination of forms, of CM exposure (e.g., sexual abuse or physical abuse).
Adolescents exposed to multiple forms of psychological trauma ("poly-victimization," Finkelhor et al. Child Abuse Negl 2007;31:7-26) may be at high risk for psychiatric and behavioral problems. This study empirically identifies trauma profiles in a national sample of adolescents to ascertain correlates of poly-victimization.
Latent Class analyses and logistic regression analyses were used with data from the National Survey of Adolescents to identify trauma profiles and each profile's risk of posttraumatic stress disorder, major depressive disorder, substance use disorders, and delinquency involvement and deviant peer group relationships. Poly-victimization classes were also compared to classes with trauma exposure of lesser complexity.
Six mutually exclusive trauma profiles (latent classes) were identified. Four classes were characterized by high likelihood of poly-victimization, including abuse victims (8%), physical assault victims (9%), and community violence victims (15.5%). Poly-victimization class members, especially abuse and assault victims, were more likely than do youth traumatized by witnessing violence or exposure to disaster/accident trauma to have psychiatric diagnosis and (independent of psychiatric diagnoses or demographics) to be involved in delinquency with delinquent peers.
Poly-victimization is prevalent among adolescents and places youth at high risk for psychiatric impairment and for delinquency. Moreover, poly-victimized youths' risk of delinquency cannot be fully accounted for by posttraumatic stress disorder, depression, or substance use problems, suggesting that adolescent healthcare providers should consider poly-victimization as a risk for behavioral and legal problems even when PTSD, depression, or addiction symptoms are not clinically significant.
This review examines the psychological impact of adult sexual assault through an ecological theoretical perspective to understand how factors at multiple levels of the social ecology contribute to post-assault sequelae. Using Bronfenbrenner's (1979, 1986, 1995) ecological theory of human development, we examine how individual-level factors (e.g., sociodemographics, biological/genetic factors), assault characteristics (e.g., victim-offender relationship, injury, alcohol use), microsystem factors (e.g., informal support from family and friends), meso/ exosystem factors (e.g., contact with the legal, medical, and mental health systems, and rape crisis centers), macrosystem factors (e.g., societal rape myth acceptance), and chronosystem factors (e.g., sexual revictimization and history of other victimizations) affect adult sexual assault survivors' mental health outcomes (e.g., post-traumatic stress disorder, depression, suicidality, and substance use). Self-blame is conceptualized as meta-construct that stems from all levels of this ecological model. Implications for curbing and/or preventing the negative mental health effects of sexual assault are discussed.
No longer confined to the criminal justice system alone, violence is now regarded as a major health care issue in America. Changes are apparent not only in health care delivery, but also in medical school curricula, residency training board examinations, and accreditation. Although tertiary prevention demands the most acute attention, opportunities for secondary prevention are important and often neglected, especially when the immediate health care issue is not related to violence. This article describes the development of the Emergency Department as a Violence Prevention Center program, established at The George Washington University Medical Center. The program moves beyond responding to acute cases of violence only and considers the hospital emergency department as an active player in a community-wide effort to end violence. It does this through universal screening, assessment, treatment and other interventions, documentation, and patient and professional education.
Among 936 demands for treatment by drug users in Greece in 7 months in 1994, 78 subjects making at least two demands were identified by code numbers. The median time between demands was 50 days (range 2-219). The data obtained by interview at the first two demands were compared to estimate the reliability of the interview schedule of the First Treatment Demand protocol of the Pompidou Group of the Council of Europe. Subjects were 84.6% male, with a median age of 27 years (range 14-43) and median duration of use 11 years (range 2-27). The primary substance of use was mainly heroin (88.5%). The percentage of agreement between interviews was highest for lifetime history of injecting (100%), urban residence (98.7%) and mode of use of heroin (94.3%). Percentages of agreement were close to 90% for most other items of socio-demographic data and drug use history, whether or not the correct response to the item could logically change between interviews. It is concluded that reliability of the data is around 90% and short-term behaviour in this population is rather stable. Only employment status (52.9% agreement) and secondary substance of abuse (25.5%) appeared to be exceptions. It is noteworthy that HIV and hepatitis serostatuses were reported less reliably than most other items.
The use of behavioural self-reports of drug users is widespread among studies of illicit drug use. Despite widespread use, concerns about the accuracy of these reports continue to be raised. The current paper critically reviews the literature on the reliability and validity of self-reported drug use, criminality and HIV risk-taking among injecting drug users. The literature shows respectable reliability and validity of self-reported behaviours when compared to biomarkers, criminal records and collateral interviews. It concludes that the self-reports of drug users are sufficiently reliable and valid to provide descriptions of drug use, drug-related problems and the natural history of drug use.
This study sought to determine prevalence of and risk factors for nonfatal recent overdose among street-recruited injection heroin users.
From August 1998 through July 1999, 1427 heroin injectors were recruited from 6 inner-city neighborhoods in the San Francisco Bay Area, Calif, and interviewed. Factors hypothesized to be associated with recent overdose were analyzed with logistic regression.
Of the 1427 participants, 684 (48%) had had an overdose, 466 (33%) had experienced 2 or more overdose events, and 182 (13%) had had a recent overdose. In multiple logistic regression, being younger (adjusted odds ratio [OR] for each year of increasing age = 0.95; 95% confidence interval [CI] = 0.94, 0.97), having been arrested 3 or more times in the past year (adjusted OR = 2.50; 95% CI = 1.61, 3.87), drinking 4 or more alcoholic drinks per day (adjusted OR = 2.05; 95% CI = 1.37, 3.05), and having participated in methadone detoxification during the past year (adjusted OR = 1.47; 95% CI = 1.03, 2.09) were independently associated with recent overdose. Being homeless; identifying as gay, lesbian, bisexual, or transgender; having spent 5 or more years in prison or jail; and having engaged in sex work also were associated with recent overdose.
Targeted interventions that decrease risk for overdose are urgently needed.
In this article I propose that gender inequality promotes--directly or indirectly--vulnerability to HIV as a consequence of a multidimensional violence (structural, symbolic and physical) experienced by injection drug using (IDU) women in The Mission District (San Francisco). Given the female subordinated position stipulated by the street ideology, I analyze how drug dependence afforded by precarious strategies of subsistence places IDU women under multiple dangers and threats. In this setting, unequal gender relations are part of a complex system of transactions in the street economy and a way to reduce or increase the everyday violence. Facing multiple dangers and risks, some women adopt a subordinated position, some try to negotiate the conditions of the exchanges and the others resist the exploitation. Finally, everyday violence under conditions of gender inequality and scarcity of resources imposes a logic defined by the challenge of survival under the threat of immediate dangers, which transform HIV into a secondary risk.
The objective of this study was to determine the prevalence of, and factors associated with, sexual violence in childhood, adolescence and adulthood, among injection drug using men and women. The Vancouver Injection Drug User Study is a prospective cohort of injection drug users (IDU) begun in 1996. The analysis included all individuals who completed the baseline questionnaire who responded to a question about sexual assault. Multivariate modeling was used to determine and to what extent a history of sexual violence at different ages is predictive of HIV risk and other health risk behaviors. HIV prevalence was calculated as the total current number of HIV-positive individuals in the cohort. Of the 1437 eligible individuals, 36% reported a lifetime history of sexual violence; 68% of women, and 19% of men (p<0.001). After adjusting for fixed sociodemographics, these individuals were more likely to have ever been in the sex trade, to knowingly share needles/rigs with HIV-positive people, to have attempted suicide, to have ever accidentally overdosed, to binge on alcohol, and to have been diagnosed with a mental disorder/disability. The prevalence of child sexual abuse in this cohort is 21%; 33% for women, and 13% for men. The data show a dose-response relationship between age at first sexual violence and most risk behaviors examined. These relationships are further mediated by gender. The prevalence of HIV among individuals who ever experienced sexual violence was 25%, compared to 19% among those who never experienced sexual violence (p=0.006). Sexual violence, and especially child sexual abuse, is highly prevalent among this cohort, particularly among women. Child sexual abuse has worse consequences for both genders than sexual violence later in life. Nevertheless, women and men are affected differently by sexual violence at different ages, and this has significant implications for health promotion programs, and specifically HIV prevention.
Screening for intimate partner violence has been advocated as an emergency department (ED) procedure. This study aimed to ascertain whether a 5-item intimate partner violence screening questionnaire could be used effectively in the ED with low-income black women to accurately predict partner abuse status.
Data were collected from 200 black women who answered in the affirmative to at least 1 item on the intimate partner violence screener questionnaire, the Universal Violence Prevention Screening Protocol. The women completed a comprehensive battery of measures, including the Index of Spouse Abuse, a commonly used and psychometrically sound measure of intimate partner violence.
Bivariate logistic regression analyses revealed that, compared with women below the physical-intimate partner violence cut point on the Index of Spouse Abuse, women above the cut point on physical-intimate partner violence on the Index of Spouse Abuse were more likely to answer yes to Universal Violence Prevention Screening Protocol screening questions related to physical, sexual, and emotional abuse; threats to be harmed physically; and being afraid. Compared with women below the nonphysical-intimate partner violence cut point on the Index of Spouse Abuse, women above the cut point on nonphysical intimate partner violence on the Index of Spouse Abuse were more likely to answer yes to each screening question on the Universal Violence Prevention Screening Protocol. The 2 Universal Violence Prevention Screening Protocol screening items related to physical abuse best predicted the 2 Index of Spouse Abuse scales. Accurate prediction of physical and nonphysical abuse on the Index of Spouse Abuse required affirmative responses to 4 or more screening questions on the Universal Violence Prevention Screening Protocol.
A brief intimate partner violence screening device in the emergency care setting can identify abused, low-income, black women. The study is limited by the fact that universal screening was not conducted, the inclusion of only women who acknowledged some form of intimate partner violence, a reliance on retrospective self-reports, and the questionable generalizability of the findings to groups other than low-income black women.
The primary aim of the study was to identify a classification scheme, for determining the predominant type of maltreatment in a child's history that best predicts differences in developmental outcomes.
Three different predominant type classification schemes were examined in a sample of 519 children with a history of alleged maltreatment. Cases were classified into predominant maltreatment types according to three different schemes: Hierarchical regression analyses examined whether the HT, SFT, and EHT type classifications contributed to prediction of child behavior problems, trauma symptoms and adaptive functioning.
After controlling for demographic factors, the HT definitions predicted four outcomes, while the SFT definitions predicted three, and the EHT classifications contributed to the prediction of five child outcomes. The co-occurrence of multiple types of maltreatment was robustly related to outcomes. However, the HT and SFT classifications predicted outcomes even after accounting for the co-occurrence of multiple maltreatment subtypes.
A classification scheme that differentiates between type combinations and single maltreatment types may have the greatest predictive validity. Over and above knowing about co-occurrence of maltreatment sub-types, it is important to understand what type, or constellation of types, of maltreatment have been alleged in a child's history.
Non-fatal overdose is a major determinant of morbidity among injection drug users (IDU). We sought to evaluate factors associated with non-fatal overdose among IDU in Vancouver.
We examined non-fatal overdose among participants in the Vancouver Injection Drug Users Study. Correlates of non-fatal overdose occurring between 1996 and 2004 were identified using generalized estimating equations (GEE).
There were 1587 participants included in this analysis, including 576 (36%) women. At baseline, 750 (47%) reported a history of non-fatal overdose. In total, 985 reports of non-fatal overdose were made during follow-up by 519 (32.7%) participants. In multivariate GEE analyses, factors independently associated with non-fatal overdose included: heroin injection (AOR=2.67), cocaine injection (AOR=2.01), benzodiazepine use (AOR=2.00), requiring help injecting (AOR=1.58), binge drug use (AOR=1.52), homelessness (AOR=1.38), alcohol use (AOR=1.32), street injecting (AOR=1.22), non-injectable opiate use (AOR=1.16), speedball use (AOR=1.15), and recent incarceration (AOR=1.14). Younger age (AOR=0.99) and methadone use (AOR=0.51) were protective.
We found that non-fatal overdose was common among local IDU. Non-fatal overdose was associated with several factors that may be amenable to intervention, including opiate and stimulant use, and the characteristic of requiring help with injecting. These findings indicate the need for the ongoing development of structural interventions to address this common cause of morbidity among IDU.
To assess the role of multiple victimization, or what is termed in this article "poly-victimization," in explaining trauma symptomatology.
In a nationally representative sample of 2,030 children ages 2-17, assessment was made of the past year's victimization experiences and recent trauma symptoms.
Children experiencing four or more different kinds of victimization in a single year (poly-victims) comprised 22% of the sample. Poly-victimization was highly predictive of trauma symptoms, and when taken into account, greatly reduced or eliminated the association between individual victimizations (e.g., sexual abuse) and symptomatology. Poly-victims were also more symptomatic than children with only repeated episodes of the same kind of victimization.
Researchers and practitioners need to assess for a broader range of victimizations, and avoid studies and assessments organized around a single form of victimization.