Article

Multiple Victimizations and Overdose Among Women With a History of Illicit Drug Use

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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.

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... 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). ...
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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).
Article
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.
Article
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.
Article
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.
Article
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.
Article
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.
Article
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).
Article
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.
Article
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.
Article
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.
Article
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.
Article
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.
Article
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.
Article
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.
Article
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.
Article
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.
Article
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).
Article
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.
Article
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.
Article
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.
Article
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.
Article
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.
Article
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.
Article
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.
Article
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.
Article
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.
Article
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.
Article
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.
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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.
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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.