Problem drug users and assault

Self-wise, Other-wise, Streetwise (SOS) training, an intervention to prevent victimization in dual-diagnosis patients: results from a randomized clinical trial

BACKGROUND AND AIMS

Patients with co-occurring substance use and other mental disorders are vulnerable to crime victimization, yet no evidence-based preventive interventions exist. Our aim was to test the efficacy of a new intervention, Self-wise, Other-wise, Streetwise training (SOS training), to prevent victimization in these dual-diagnosis patients as an add-on to care as usual.

DESIGN

Multi-site single-blind parallel randomized controlled trial.

SETTING

Three sites within one psychiatric service in Amsterdam, the Netherlands.

PARTICIPANTS

Adult in-patients and out-patients with dual diagnosis (n = 250), who were predominantly male (70.4%), aged on average 42.1 years, and diagnosed with 3.7 DSM-IV disorders.

INTERVENTION AND COMPARATOR

Care as usual, consisting of pharmacotherapy combined with individual psychotherapy, group psychotherapy and/or supportive counselling (n = 125) was compared with care as usual plus SOS training: a 6-week, 12-session manualized group training focused on enhancing emotion regulation skills, conflict resolution skills and street skills (n = 125).

MEASUREMENTS

Victimization was assessed with the Safety Monitor, the Dutch equivalent of the International Crime Victims Survey, in a face-to-face assessment. The primary outcome measure was treatment response (yes/no), with 'yes' defined as reporting at least a 50% reduction in the number of past-year victimization incidents at the 14-month follow-up compared with baseline. Analyses were performed according to the intention-to-treat principle.

FINDINGS

The proportion of participants achieving treatment response for total victimization was 54.0% in the control group and 67.6% in the experimental group, a significant difference [odds ratio (OR) = 1.78, 95% confidence interval (CI) = 1.02-3.11, P = 0.042]. Treatment response for violent victimization was achieved by 68.7% of the control group and 79.3% of the experimental group (OR = 1.75, 95% CI = 0.91-3.34, P = 0.092). With a Bayes factor of 2.26, this result was inconclusive.

CONCLUSIONS

Among dual-diagnosis patients, care as usual plus Self-wise, Other-wise, Streetwise training was more effective in preventing victimization than care as usual alone.

Risk of violence in drug rehabilitation centers: perceptions of people who inject drugs in Tijuana, Mexico

Background

In 2009, Mexico reformed its health law to partially decriminalize drug possession considered for personal use and to increase mandatory referrals to certified drug rehabilitation centers in lieu of incarceration. Concurrently, news media reported violent attacks perpetrated by drug cartels against Mexican drug rehabilitation centers and instances of human rights violations by staff against people who inject drugs (PWID) in treatment. In many cases, these violent situations took place at “Peer Support” (Ayuda Mutua) drug rehabilitation centers that house a large number of drug-dependent PWID. In an effort to understand barriers to treatment uptake, we examined prevalence and correlates of perceived risk of violence at drug rehabilitation centers among PWID in Tijuana, Mexico.

Methods

Secondary analysis of baseline data collected between March 2011 and May 2013 of PWID recruited into a prospective cohort study in Tijuana. Interviewer-administered surveys measured perceived risk of violence at drug rehabilitation centers by asking participants to indicate their level of agreement with the statement “going to rehabilitation puts me at risk of violence”. Logistic regression was used to examine factors associated with perceived risk of violence.

Results

Of 733 PWID, 34.5 % perceived risk of violence at drug rehabilitation centers. In multivariate analysis, reporting ever having used crystal methamphetamine and cocaine (separately), having a great or urgent need to get help for drug use, and ever receiving professional help for drug/alcohol use were negatively associated with perceived risk of violence at drug rehabilitation centers, while having been told by law enforcement that drug rehabilitation attendance is mandatory was positively associated with perceived risk of violence. All associations were significant at a 0.05 alpha level.

Conclusion

The perception of violence at drug rehabilitation centers among PWID does not represent the lived experience of those PWID who attended professionalized services, reported a great or urgent need to get help for their drug use and had a history of using crystal and cocaine. Professionalizing service delivery and engaging law enforcement in their new role of decriminalization and service referral for PWID could address the perceptions of violence at drug rehabilitation centers. Similarly, health authorities should expand periodic inspections at drug rehabilitation centers to guarantee quality service provision and minimize PWIDs’ concerns about violence.

Electronic supplementary material

The online version of this article (doi:10.1186/s13011-015-0044-z) contains supplementary material, which is available to authorized users.

Potential Years of Life Lost Due to Premature Mortality Among Treatment-Seeking Illicit Drug Users in Finland

Premature death is a serious public health concern. The primary objective of this study was to examine premature deaths in terms of potential years of life lost (PYLL) in a cohort of 4817 treatment-seeking illicit drug users. Clients' data were linked to the Finnish national cause-of-death register and the follow-up period ranged from 31 January 1997 to 31 December 2010. PYLL before 70 years was calculated for all deaths and cause-specific deaths by gender. We observed 496 deaths (417 males and 79 females) at the end of 2010. The mean age at death was 33.8 years, 34.3 years for males (range 18-68) and 31.4 years for females (range 16-53). Overall, 17,951 life years were lost; 14,898 among males and 3053 among females. The overall PYLL rate for males was more than twice that of females (513.0/1000 vs. 243.7/1000 person-years) but the mean PYLL was higher in females than males (38.6 vs. 35.7 years). Of the total PYLL, 34.8 % was due to accidental overdose, and 24.0 % to suicide. In both genders, accidental overdose and suicide were the two top-ranking causes of PYLL. Premature deaths among drug users are a potential loss to the society. Our findings suggest that measures targeting accidental overdose and suicide are top priorities for reducing preventable loss of life.

Violent offending severity among injecting drug users: examining risk factors and issues around classification

OBJECTIVE

There is a paucity of research as to how injecting drug users (IDU) might be differentiated in the severity of their violent offending. This paper reported on the risks associated with severity, as well as issues around severity classification and the impact on observed relationships with known major risk factors.

METHOD

A cross-sectional survey administered to 300 IDU, who had injected drugs weekly or more in the past 12months. A structured questionnaire addresses potential substance use and early-life risk factors for violent offending.

RESULTS

Four severity groups were identified: non-violent (24%), low (34%), moderate (22%) and high (20%) level offenders. Higher severity groups had more prevalent and more severe histories of childhood maltreatment, child psychopathology and dysfunctional trait personalities, as well as more severe substance use problems than low-level and non-violent IDU. Regression analyses found that only two of 15 risk factors remained uniformly associated with violent offending across the four classification schemes tested: (1) having committed violence under the influence and (2) having more impulsive trait personalities.

CONCLUSIONS

Disaggregating IDU into distinct subgroups showed that the extent and severity of predispositional and substance use risk exposure corresponded to the severity of violent offending. There is a need to establish a systematic method for classifying severity given that there were clinically meaningful differences between groups which require further exploration and replication, and because there was extensive variation in the risks associated with severity across schemes.

Associations between substance use, post-traumatic stress disorder and the perpetration of violence: A longitudinal investigation

AIM

Substance use disorder (SUD) and post-traumatic stress disorder (PTSD) commonly co-occur. This is of significant concern, given the increased risk for violence perpetration among individuals with this comorbidity. Limited research, however, has examined relationships between SUD, PTSD and violence among individuals longitudinally. Such an investigation is warranted given that substance use and PTSD symptoms can fluctuate over time. This study therefore aims to examine how changes in substance use and PTSD symptom severity are associated with the perpetration of violent crime over time among individuals with comorbid SUD and PTSD.

METHOD

One-hundred and two men and women who met criteria for SUD and PTSD were interviewed four times over a 9-month period. These interviews included measures of past-month violent crime perpetration, substance use and dependence, PTSD symptom severity, and depression and state anxiety symptoms. Generalised estimating equations (GEE) modelled associations between substance use, PTSD and violence.

RESULTS

Increased substance use, more severe substance dependence and more severe PTSD symptomology were consistently associated with violent crime over time. Multivariate GEE analyses, however, revealed that the PTSD hyperarousal symptoms, specifically, were independently associated with violence over time.

CONCLUSIONS

This longitudinal study found that PTSD hyperarousal symptoms were consistently associated with the perpetration of violent crime, further highlighting the potentiating role of PTSD hyperarousal in relation to violence among individuals with SUD. These findings indicate that interventions addressing hyperarousal symptoms have the potential to reduce the susceptibility for violence among individuals with this common comorbidity.

The association of early-life and substance use risks to violent offending among injecting drug users

INTRODUCTION AND AIMS

It remains unclear whether violent offending among injecting drug users (IDU) is the direct result of drug use factors or whether they are predisposed to violent behaviour from childhood. The current study sought to identify substance use and early-life correlates of lifetime violent offending among IDUs and to determine what risks contributed to recent violent offending.

DESIGN AND METHODS

Three hundred community-based regular IDUs were administered a face-to-face cross-sectional structured interview examining correlates of violent offending.

RESULTS

One-third (34%) of IDUs had committed violence in the past 12 months, 42% more than 12 months ago and 24% had never been violent. Predispositional and substance use risk profiles were poorer among IDUs who had been violent, but many of these risks were even more prevalent and severe among those who had been violent in the past 12 months. Multinomial logistic regression found that IDUs who had been violent in the past 12 months had greater polysubstance and higher trait aggressive personalities than the other IDUs, whereas they were further differentiated from non-recent violent IDUs in having more involvement in drug dealing and more likely to screen positive for conduct disorder.

DISCUSSION AND CONCLUSIONS

Drug use factors alone did not adequately explain the likelihood of violent offending among IDUs. Instead, there appeared to be complex interactions between early-life risks and substance use which created a liability to violent offending, and the level of exposure to these risks appeared to explain differences in violent offending patterns.

Injection drug users' involvement in drug dealing in the downtown eastside of Vancouver: social organization and systemic violence

BACKGROUND

Illicit drug markets are a key component of the risk environment surrounding injection drug use. However, relatively few studies have explored how injection drug users' (IDUs) involvement in drug dealing shapes their experiences of drug market-related harm. This exploratory qualitative study aims to understand IDUs' dealing activities and roles, as well as the perceived benefits and risks related to participation in illicit drug markets, including experiences of drug market violence.

METHODS

Ten IDUs with extensive involvement in drug dealing activities were recruited from the Vancouver Injection Drug User Study (VIDUS) and participated in semi-structured qualitative interviews, which elicited discussion of experiences dealing drugs, perceived benefits and hazards related to dealing, and understandings of drug market violence.

RESULTS

Participant's involvement in drug market activities included corporate sales, freelance or independent sales, and opportunistic sales termed "middling" as well as drug market-related hustles entailing selling bogus drugs and robbing dealers. Participants primarily dealt drugs to support their own illicit drug use, and we found that arrest and criminal justice involvement, hazards stemming from drug debts, and drug market-related violence were key risks related to dealing activities.

CONCLUSION

The challenges of managing personal consumption while selling drugs exacerbates the hazards associated with drug dealing. Efforts to address drug dealing among IDUs should consider both drug dependency and the material conditions that propel drug users towards dealing activities. Interventions should explore the potential of combining enhanced drug treatment programs with low threshold employment and alternative income generation opportunities.

Injection drug users' and their risk networks' experiences of and attitudes towards drug dealer violence in Baltimore, Maryland

BACKGROUND

A large portion of violence associated with drug use is due to drug dealing. These analyses sought to examine injection drug users' attitudes and experiences of drug dealer violence.

METHODS

The current study used the 18-month follow up data of STEP into Action (STEP) study, an HIV prevention intervention among drug injectors and their risk network members conducted in Baltimore, Maryland. Four scales assessed acceptability of drug dealer violence, willingness to talk to drug users about avoiding drug dealer violence, social norms about reporting drug dealer violence and intentions to report drug dealer violence to the police.

RESULTS

Many (44%) of the 373 participants reported witnessing drug dealers' acts of violence within the prior 6 months. Although the majority of participants disagreed with statements on the acceptability of dealers using violence, only a minority indicated that they would call the police if they observed dealer violence. Most participants indicated that they would be interested in talking to drug users about how to avoid violent dealers. Males were more likely to report that violence was acceptable, whereas African Americans were less likely to condone violence. Those who were homeless and had higher incomes were more likely to report witnessing drug dealer violence.

CONCLUSIONS

These results suggest that it may be feasible to train current and former drug users and their risk network members in methods to promote violence reduction among drug dealers.

Conduct Disorder as a Risk Factor for Violent Victimization and Offending among Regular Illicit Drug Users

This paper aimed to examine the prevalence, correlates and nature of violent crime by, and upon, regular drug users by conduct disorder (CD) status. Interview data was collected from 299 regular psychostimulant and/or opioid users. Conduct disorder significantly increased the lifetime and past 12 month risk of violent victimization and offending. While CD did not independently predict recent violent victimization, it did predict recent violent offending. Greater alcohol dependence and involvement in drug dealing were predictors of both recent victimization and offending. The study indicates that there is significant temporal stability between childhood CD behaviors and later violent behavior among individuals with substance use problems. The study also highlights that there is heterogeneity in the risk of violence exposure in drug using populations, a finding which has implications for early intervention and for treatment interventions among dependent drug user populations.