Childhood sexual abuse characteristics, intimate partner violence exposure, and psychological distress among women in methadone treatment

Trauma Prevalence and Its Association With Health-related Quality of Life in Pregnant Persons With Opioid Use Disorder

OBJECTIVES

Trauma screening is recommended for pregnant persons with opioid use disorder (OUD), but there is limited literature on screening results from buprenorphine treatment. This study's objectives were to 1) describe the types, and severity, of traumatic events reported and 2) evaluate the associations between trauma and health-related quality of life (HRQoL).

METHODS

Baseline data from an ongoing trial were analyzed. Participants were 155 pregnant persons with OUD receiving, or enrolling in, buprenorphine treatment at one of 13 sites. The experience, and relative severity, of 14 high magnitude stressors were assessed with the trauma history screen. The Patient-Reported Outcomes Measurement Information System-29+2 was used to assess 8 HRQoL domains.

RESULTS

Traumatic stressors were reported by 91% of the sample (n = 155), with 54.8% reporting a lifetime persisting posttraumatic distress (PPD) event and 29.7% reporting a childhood PPD event. The most prevalent lifetime PPD event was sudden death of a close family/friend (25.8%); physical abuse was the most prevalent childhood PPD event (10.3%). Participants with lifetime PPD, relative to no PPD, reported significantly greater pain interference ( P = 0.02). Participants with childhood PPD, relative to no PPD, had significantly worse HRQoL overall ( P = 0.01), and worse pain intensity ( P = 0.002), anxiety ( P = 0.003), depression ( P = 0.007), fatigue ( P = 0.002), and pain interference ( P < 0.001).

CONCLUSIONS

A majority of pregnant persons enrolled/enrolling in buprenorphine treatment reported persisting posttraumatic distress with sudden death of close family/friend being the most prevalent originating event; clinicians should consider the impact that the opioid-overdose epidemic may be having in increasing trauma exposure in patients with OUD.

Parenting Among Women in Methadone Treatment: Contributions of Mental Health Problems and Violence Exposure

The aim of the current study is to explore factors associated with quality of parenting among women in treatment for opioid use disorders. 150 Black American women with 3-5 year old children were recruited through methadone treatment programs. Parenting representations were assessed through the Working Model of the Child Interview and parenting behavior through video recordings of mother-child interaction. Interviews were used to assess mothers' history of violence exposure and to make DSM diagnoses. Mothers' mood disorder was related to distorted representations and to expressions of concerned affect (anxiety, fear, guilt). Mothers' personality disorder was related to expressions of negative affect (anger and frustration) and inversely related to sensitive parenting behavior. Mothers' experience of family violence during childhood and partner violence during adulthood were related to concerned affect in their representations. Women in treatment for substance use disorder have complex and interconnected needs, including parenting supports and trauma-informed mental health services.

Synergistic effects of exposure to multiple types of violence on non-fatal drug overdose among women who inject drugs in Indonesia

BACKGROUND

While research has demonstrated associations between experiencing violence from intimate and non-intimate partners and non-fatal drug overdose among women who inject drugs, existing studies focus predominantly on the Global North and are analytically limited. Guided by syndemics theory, this study examined whether different forms of gender-based violence exert independent and interactive effects on non-fatal drug overdose among women who inject drugs in Indonesia.

METHODS

We recruited 731 cisgender adult women who injected drugs in the preceding year via respondent-driven sampling. We used multivariate logistic regressions to examine associations between self-reported intimate partner violence (IPV), police sexual violence, and police extortion, and non-fatal drug overdose, with covariance adjustment for factors drawn from the risk environment. We tested for interaction effects among violence measures by calculating metrics for attributable proportion (AP), relative excess risk due to interaction (RERI), and synergy index (S).

RESULTS

Experiencing IPV (AOR 2.5; 95 % CI 1.2, 5.1; p = 0.012), police extortion (AOR 2.2; 95 % CI 1.5, 3.2; p ≤ 0.001), and police sexual violence (AOR 3.7; 95 % CI 1.5, 9.4; p = 0.005) each independently predicted non-fatal overdose, after adjusting for potential confounders. A significant positive interaction was detected between IPV and police sexual violence on drug overdose (AP=0.6, p = 0.001; S = 3.8, p = 0.015) such that the joint effect of these two forms of violence was associated with a nearly fourfold increase in non-fatal overdose risk compared to the main effects of each violence exposure.

CONCLUSION

This is the first study to show that concurrent IPV and police sexual violence exert an amplifying effect on non-fatal overdose beyond the additive effects of each exposure. Supporting the value of gender-responsive harm reduction services that integrate violence and overdose responses, results suggest that eliminating one form of violence when multiple forms of GBV are present could magnify the expected reduction in overdose.

"You rise up and then you start pulling people up with you": Patient experiences with a peer-delivered behavioral activation intervention to support methadone treatment

BACKGROUND

Although medications for opioid use disorder (MOUD) are efficacious treatments for opioid use disorder, retention remains low. Peer recovery specialists (PRSs), individuals with lived substance use and recovery experience, may be particularly well-suited to support patients receiving MOUD. While PRSs are rarely trained in evidence-based behavioral interventions other than motivational interviewing, preliminary evidence suggests that peers can deliver brief behavioral interventions, such as behavioral activation, with efficacy and fidelity. This qualitative study sought to explore patient perspectives on receiving an adapted PRS-delivered behavioral activation intervention (Peer Activate) to support patients receiving methadone treatment.

METHODS

The sample (N = 26) included patients recently starting or demonstrating challenges with adherence at a community-based methadone treatment program who received the Peer Activate intervention in a pilot trial. Participants were invited to participate in in-depth, semi-structured interviews at study completion or discontinuation, assessing perceived acceptability and feasibility of Peer Activate, and stigma-related barriers. Interview transcripts were coded using codebook/template thematic analysis.

RESULTS

Analysis revealed the importance of two areas to promote intervention acceptability: 1) connection with intervention content and skill building, and 2) valued PRS-specific qualities. Intervention flexibility was found to promote feasibility of the intervention in the context of chaotic and challenging life circumstances. Additionally, participants described stigma towards substance use and methadone treatment as potential barriers to engaging in methadone treatment.

CONCLUSION

Results support the acceptability and feasibility to patients of this PRS-delivered behavioral activation intervention in the context of outpatient MOUD treatment among a low-income, majority racially minoritized patient population. Future intervention adaptation and implementation should focus on incorporating content related to relationships and interpersonal skills; balancing behavioral intervention content with system navigation support; maintaining flexibility; and further investigation of the impact of individual PRS attributes, including shared lived experiences, on intervention acceptability and shifts in stigma.

Opioids and Opioid Use Disorder in Pregnancy

Overdose is a leading cause of pregnancy-associated morbidity and mortality in the United States. As such, all obstetric providers have a responsibility to provide evidence-based care for patients with opioid use disorder to mitigate adverse outcomes associated with substance use during pregnancy.

Intimate partner violence as a predictor of substance use outcomes among women: A systematic review

Although the correlation between experience of intimate partner violence (IPV) and substance use among women has been well-established, there is no consensus on whether or how IPV impacts subsequent substance use behaviors or treatment success. To identify research gaps and implications for substance use treatment, we conducted a systematic review to identify and examine evidence on IPV as a predictor of subsequent substance use behaviors, substance use disorders (SUD), and treatment outcomes among women. We included studies published between 2010 and 2020 that assessed IPV experiences as a predictor of subsequent substance use behaviors (i.e., use initiation, increased use), SUD diagnosis, or treatment outcomes (i.e., incomplete treatment, relapse) among women. From 576 unique records, we included 10 studies (4 longitudinal, 4 cross-sectional, 2 qualitative). Alcohol use and alcohol use disorder were the most commonly studied outcomes (n = 6); findings were mixed regarding the significance of IPV being associated with subsequent alcohol outcomes. Three studies examined illicit drug use, finding that physical and sexual IPV predicted crack/cocaine use and were associated with SUD diagnoses. Four studies examining SUD treatment outcomes found IPV to impede treatment engagement and completion, increasing the likelihood of relapse. To our knowledge, this is the first systematic review of the literature on IPV as a predictor of substance use behaviors and treatment outcomes among women. Findings highlight the need for diverse SUD treatment modalities to incorporate IPV screening and referral to appropriate services into their programming to improve SUD management and the overall health and wellbeing of women.

Current of Child Sexual Abuse in Asia: A Systematic Review of Prevalence, Impact, Age of First Exposure, Perpetrators, and Place of Offence

BACKGROUND: Child sexual abuse (CSA) is a serious global problem and challenge for all people because it increases the risk of various issues. AIM: This study investigated the CSA in Asian countries focusing on prevalence rates, impact, victim’s age of first exposure, type of CSA, perpetrator, and places of CSA offence. METHODS: We searched PubMed, Medline, ProQuest, ScienceDirect, CINAHL, Academic Search Complete, ClinicalKey, PsycINFO, Google Scholar, and manual search for studies published between January 2011 and November 2020. Only articles related to CSA in Asia were included in this review. RESULTS: The results showed that prevalence of CSA ranged from 2.2% - 94% for girls and 1.7% - 49.5% for boys. The prevalence rates for non-contact abuse were 12.6% - 56.5% for girls and 0.7% - 68.7% for boys; contact abuse was 5.3% - 67.2% for girls and 2.2% - 53.3% for boys; penetrating abuse was 0.5% - 88.24% for girls and 1.7% - 57.1% for boys. The findings reported most victims’ age of first exposure was preteen. The rate of the violation occurring in the victim’s house was 6.1% - 41.9%; most CSA perpetrators are known by victims. This study reported adverse impacts on CSA victims such as psychological, health, and physical disorders, and changes in behavior. In addition, other findings were found, including recovery, perceptions, values, causes, and expectations of victims of CSA. CONCLUSIONS: The incidence of CSA in Asia is still high and the age of the first victims is early adolescence. The majority of victims are women who already know the perpetrator, and taboo cultural factors are thought to play a role in increasing CSA in Asia. The results indicate the need to develop CSA prevention efforts that involve culture.

Barriers to help-seeking among intimate partner violence survivors with opioid use disorder

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.

Addiction treatment in the postpartum period: an opportunity for evidence-based personalized medicine

Substance use disorders (SUD) are becoming rapidly more prevalent in women and a leading cause of pregnancy associated deaths, with most deaths occurring during the 12 months after pregnancy. The postpartum period can be quite intense, especially for women seeking addiction recovery. There is a call to reconceptualize the obstetrical postpartum care model into one that extends specialised care and is tailored to an individual's specific needs. Although SUD treatment improves maternal and infant outcomes as well as decreases overdose risk, many women do not receive consistent SUD treatment during the postpartum period. Thus, SUD treatments should consider following the same guidance as obstetrics to reconceptualize how SUD treatment is delivered postpartum. Clinically, this translates into substantially modifying traditional siloed SUD treatment structures to meet the unique needs of this vulnerable patient population. At the same time, more research is urgently needed to inform these advancements in clinical care to ensure they are evidence-based and effective. In this article, we review the existing evidence as well as highlight opportunities for both clinicians and researchers to advance the integration of tailored approaches for postpartum women into personalised SUD medical and behavioural treatments.

Does Childhood Psychological Abuse Contribute to Intimate Partner Violence Victimization? An Investigation Using the Childhood Experience of Care and Abuse Interview

Although psychological abuse is recognized as a particularly insidious form of child abuse, research on the impact of this type of abuse related to intimate partner violence (IPV) is scant. This study examined the contribution of childhood psychological abuse to IPV in female victims and non-victims. Furthermore, it investigated the role of cumulative abuse in predicting IPV. The study included 38 women victims of IPV and 40 non-IPV women. All participants were investigated using the Childhood Experience of Care and Abuse Interview (CECA); the Revised Conflict Tactics Scale (CTS2) and the IPV History Interview were used to assess IPV in the last year and lifetime, respectively. Results indicated that psychological abuse was a stronger predictor of IPV than other maltreatment types. Furthermore, dose-response effects of cumulative abuse on IPV are well evidenced. Future research should continue examining impacts of psychological abuse on IPV so as to further inform clinical practice and intervention planning.

Sex and female empowerment (SAFE): A randomized trial comparing sexual health interventions for women in treatment for opioid use disorder

BACKGROUND

Unintended pregnancies are prevalent among women with opioid use disorder (OUD). The Sex and Female Empowerment (SAFE) project developed a social-cognitive, theory-driven intervention to increase acceptance of and adherence to contraceptive practices among women receiving medication for OUD (MOUD). This study evaluated the feasibility and acceptability of two SAFE interventions (Face-to-face and Computer-adapted) compared to usual care as well as their efficacy to improve contraception utilization.

METHODS

This pilot randomized trial enrolled 90 heterosexual, non-pregnant, reproductive-age women receiving MOUD. Participants were randomized into either a: SAFE Face-to-face intervention, SAFE Computer-adapted intervention, or usual care (UC) condition (n = 30 each) and followed for 6 months. Outcome measures included intervention completion, intervention satisfaction, attendance at a contraception consultation appointment, and long-acting reversible contraceptive (LARC) method receipt. A generalized linear model was used for inferential testing and to estimate least squares means (predicted probabilities for binary outcomes) and their standard errors.

RESULTS

Compared to the UC condition, both the SAFE Face-to-face and the SAFE Computer-adapted intervention had higher intervention completion [Means (Standard Errors) = 0.97 (.03) and 0.97 (.03), respectively, vs. 0.53 (.09); ps<.001], higher intervention satisfaction [Ms (SEs) = 3.7 (.11) and 3.8 (.11), respectively, vs. 3.1 (.11); ps<0.001), higher contraception consultation visit attendance [Ms(SEs) = 0.80 (.07) and 0.73 (.08) vs. 0.33 (.09); p < .001], and greater LARC receipt [Ms(SEs) = 0.77 (.08) and 0.73 (.08) vs. 0.23 (.08); p < .001).

CONCLUSIONS

SAFE appears feasible and efficacious for supporting women in contraception decision-making. Integrating SAFE into women's comprehensive OUD treatment services holds promise to increase contraceptive decision-making and initiation of a chosen method.

Prevalence of childhood maltreatment among people with opioid use disorder: A systematic review and meta-analysis

BACKGROUND

Experience of childhood maltreatment (CM) is a risk factor for opioid use disorder (OUD). CM is also associated with comorbid mental disorders and poor treatment outcomes among people with OUD. To our knowledge, this is the first systematic review and meta-analysis to estimate the prevalence of CM among people with OUD.

METHODS

We searched MEDLINE, EMBASE, and PsycINFO to identify observational studies that evaluated CM among people with OUD from January 1990 to June 2020. Prevalence of each CM type, sample characteristics, and methodological factors were extracted from each eligible study. Random-effects meta-analyses were used to pool prevalence estimates. Stratified meta-analyses were used to assess heterogeneity.

RESULTS

Of the 6,438 publications identified, 113 studies reported quantitative CM data among people with OUD and 62 studies (k = 62; N = 21,871) were included in primary analyses. Among people with OUD, the estimated prevalence of sexual abuse was 41% (95% CI 36-47%; k = 38) among women and 16% (95% CI 12-20%; k = 25) among men. Among all people with OUD, prevalence estimates were 38% (95% CI 33-44%; k = 48) for physical abuse, 43% (95% CI 38-49%; k = 31) for emotional abuse, 38% (95% CI 30-46%; k = 17) for physical neglect, and 42% (95% CI 32-51%; k = 17) for emotional neglect. Sex, history of injecting drug use, recruitment methods, and method of assessing CM were associated with substantial heterogeneity.

CONCLUSIONS

People with OUD frequently report the experience of CM, supporting the need for trauma-informed interventions among this population. Future research should consider the impact of CM on OUD presentations and when assessment is appropriate, use of validated instruments.

Environmental Dysfunctions, Childhood Maltreatment and Women's Intimate Partner Violence Victimization

Childhood maltreatment is considered a crucial explanatory variable for intimate partner violence (IPV) in adulthood. However, a developmental multifactorial model for the etiology of IPV is not shared by researchers yet. This study has investigated the role of a wide range of childhood maltreatments and family and social dysfunctions in predicting IPV; furthermore, it tests a model where childhood maltreatment mediates the relationship between environmental dysfunctions and IPV. The sample included 78 women: IPV (38) and non-IPV (40). The Italian version of the Childhood Experience of Care and Abuse (CECA) Interview was used to assess the presence of adverse childhood experiences. The Revised Conflict Tactics Scale (CTS-2) and the IPV History Interview were used to assess IPV in the last year and lifetime, respectively. The results of a multivariate logistic regression model have indicated that only sexual (odds ratio [OR] = 4.24) and psychological (OR = 3.45) abuse significantly predicted IPV; with regard to association between IPV and environmental dysfunctions, only poor social support (OR = 8.91) significantly predicted IPV. The results of a mediation model have shown that childhood psychological and sexual abuse, in association with each other, partially mediate the relationship between poor social support and IPV. The findings from this study pinpoint poor social support as an important predictor of IPV so far neglected in the literature on the developmental antecedents of IPV. They also support the theoretical assumption according to which dysfunctional environmental variables and types of childhood maltreatment interacting with each other may influence development outcomes.

[Unexpected pregnancy, experience of sexual violence and contraception among women who use cannabis or other illegal substance in the Great Paris Region: Data from the 2016 Health Barometer]

BACKGROUND

Women who use psychoactive substances could have higher levels of unplanned pregnancy and of difficulties accessing long-term contraceptive methods than those who do not use these substances. General population data on this topic are rare, particularly in France.

METHODS

This study is based on data from the French Health Survey 2016, collected from women aged 15 to 49 years and living in the Great Paris region (N=1626). Use of illegal psychoactive substances (cannabis, substances used via intranasal or intravenous administration) were evaluated over the lifecourse and, for cannabis, over the 12 months preceding the study. Unplanned pregnancies were ascertained over the preceding 5 years, emergency contraception, abortion, and the experience of sexual violence during the lifecourse. We also studied the number of sexual partners in the preceding 12 months, as well as current contraception. Data were analyzed using weighted logistic regression models, adjusted for participants' sociodemographic characteristics and tobacco use.

RESULTS

Women who use illegal substances have a higher probability than non-users to experience an unplanned pregnancy in the preceding 5 years (OR associated with lifecourse cannabis use: 1.61, 95% CI 1.00-2.58), to have used emergency contraception (ORs between 2.20 to 2.90), to have had an abortion (OR associated with lifecourse cannabis use: 1.77, 95% CI 1.26-2.49), and to have experienced sexual violence (ORs between 1.87 to 3.14). They also had more sexual partners than non-users, but did not differ in terms of contraception.

CONCLUSION

In the general population, there is a relationship between women's use of illegal substances and their probability of experiencing sexual violence. These results should be brought to the attention of health professionals in contact with women, to help identify those who have addictive behaviors and identify their sexual and reproductive health needs.

Pain, Opioids, and Pregnancy: Historical Context and Medical Management

Women are being disproportionately affected by the opioid crisis, including during pregnancy. Pain and other vulnerabilities to addiction differ between men and women. Management of opioid use disorder should be gender informed and accessible across the lifespan. During pregnancy, care teams should be multidisciplinary to include obstetrics, addiction, social work, anesthesia, pediatrics, and behavioral health. Pain management for women with opioid use disorder requires tailored approaches, including integration of trauma-informed care and addressing psychosocial needs. Thus, coordinated continued care by obstetric and addiction providers through pregnancy into postpartum is key to supporting women in recovery.

The Effects of Child and Adult Victimization on Psychological Distress: A Mediated Structural Equation Modeling Analysis

Justice-involved women experience significantly higher rates of victimization and psychological distress, and these experiences place women at greater risk of initial and ongoing involvement in the criminal justice system. This research explored the relationship between victimization, the hypothesized mediators (social support and coping), and psychological distress among a sample of 406 victimized women on probation/parole. Results of the Structural Equation Modeling (SEM) were significant and indicated a partial mediation model (74%) with both direct and indirect effects. Based upon the results of this research, implications and future research are explored regarding gender-responsive practices for this population.

Sexual Functioning and Opioid Maintenance Treatment in Women. Results From a Large Multicentre Study

Opioid maintenance treatment (OMT) is the most widespread therapy for both females and males opioid addicts. While many studies have evaluated the OMT impact on men's sexuality, the data collected about the change in women's sexual functioning is still limited despite the fact that it is now well-known that opioids - both endogenous and exogenous - affect the endocrine system and play an important role in sexual functioning. The present study aims to determine how OMT with buprenorphine (BUP) or methadone (MTD) affects sexual health in women; examining also any possible emerging correlation between sexual dysfunction (SD), type of opioid and patients' mental health. This multi-center study case recruited 258 female volunteers attending Italian public Addiction Outpatients Centers that were stabilized with OMT for at least 3 months. SD was assessed with the Arizona Sexual Experience Scale. The twelve-item General Health Questionnaire was used to assess participants' mental health conditions. The results show that 56.6% of women receiving OMT for at least 3 months presented SD without significant differences between MTD e BUP groups. The majority of the subjects with SD have a poorer quality of intimate relationships and worse mental health than the average. To the best of our knowledge, the present study is the largest report on the presence of SDs in women as a side effects of MTD and BUP used in OMT. Since SDs cause difficulties in intimate relationships, lower patients' quality of life and interfere with OMT beneficial outcomes, we recommend that women undertaking an opioid therapy have routine screening for SD and we highlight the importance to better examine opioid-endocrine interactions in future studies in order to provide alternative potential treatments such as the choice of opioid, opioid dose reduction and hormone supplementation.

"They didn't give up on me": a women's transitions clinic from the perspective of re-entering women

BACKGROUND

Women recently released from incarceration have increased rates of co-occurring substance use, physical health, and mental health disorders. During re-entry, they face challenges navigating needed health services and social services stemming from these problems. Women's Initiative Supporting Health Transitions Clinic (WISH-TC) is a primary care program that facilitates treatment access for re-entering women. Strategies include support and navigation assistance from peer community health workers.

METHODS

Thirteen participants, of whom 11 had a substance use disorder, completed semi-structured interviews about their experiences in WISH-TC as part of a process evaluation. We conducted a qualitative framework analysis informed by self-determination theory.

RESULTS

WISH-TC supported autonomy as staff helped motivate women to work toward personal health goals. Women were empowered to have their health needs met, and consequently, prioritized attending clinic. Regarding competence, WISH-TC built upon women's existing knowledge to increase their health literacy and better understand their individual health needs. Relatedness support, both prior to re-entry and ongoing with clinic staff, was key in women's satisfaction with their care. The clinic made procedural changes in response to the interviews, including providing orientation for the patients and training the clinic in trauma-informed practices.

CONCLUSIONS

Our findings highlight the potential of a program for re-entering women, including those with substance use disorders to strengthen their abilities to navigate complex healthcare and societal systems. WISH-TC helped women feel supported, motivated, and competent to address their substance use, physical, and mental health conditions.

Methadone maintenance treatment patients with a history of childhood trauma succeed more in a cognitive paradigm that is associated with a negative reward

Previously we showed that methadone maintenance treatment (MMT) patients displayed difficulties in generalization and reversal learning in the presence of drug-related context, compared to prolonged abstinence individuals. We now tested how history of childhood trauma, affects their reversal learning abilities. Fifty-one MMT patients were evaluated on a performance- based paradigm which assesses the ability to acquire and reverse stimulus-outcome associations in neutral and drug-related context. Patients with a history of childhood trauma (n = 32) as compared to patients without such a history showed decreased ability to learn associations with positive outcome, and had poorer performance in drug compare to neutral-related context. Most importantly, while individuals with childhood trauma history showed higher success rates in conditions of positive to negative reversals, an opposite pattern was observed in conditions of negative to positive reversal; whereas patients with trauma history preformed significantly worse than patients with no history. The results are in line with other studies which tested the effects of childhood trauma both in clinical and in healthy populations. Recognizing this trait that more disturbed by drug related context, may contribute to develop and improve personalized treatments which takes into account the difficulties as well as the strength associated with childhood trauma.

Neonatal abstinence syndrome

Neonatal abstinence syndrome refers to the signs and symptoms attributed to the cessation of prenatal exposure (via placental transfer) to various substances. This Primer focuses on neonatal abstinence syndrome caused by opioid use during pregnancy - neonatal opioid withdrawal syndrome (NOWS). As the global prevalence of opioid use has alarmingly increased, so has the incidence of NOWS. NOWS can manifest with varying severity or not at all, for unknown reasons, but is likely to be associated with multiple factors, both maternal (for example, smoking and additional substance exposures) and neonatal (gestational age, sex and genetics). Care for the infant with NOWS begins with addressing the issues experienced by pregnant women with opioid use disorder. Co-occurring mental illness, economic hardship, intimate partner violence, infectious diseases and limited access to care are common in these women and can result in poor maternal and neonatal outcomes. Although there is no consensus regarding optimal NOWS management, non-pharmacological interventions (such as breastfeeding and rooming-in of the mother and the baby) have become a priority, as they can ameliorate symptoms without the need for further opioid exposure. Untreated NOWS can be associated with morbidity in early infancy, and the long-term consequences of fetal opioid exposure are only beginning to be understood.

Facets of Male Violence Against Women With Substance Abuse Problems: Women With a Residence and Homeless Women

The aims of this study were to investigate the type and extent to which women with substance abuse problems have been exposed to male violence during their lifetime, and to examine possible differences between women with a residence (WR) and homeless women (HW). The total sample included 79 women (WR, n = 35; HW, n = 44; M age = 47.8 years). Of the total sample, 72 women (91%) had experienced different kinds of male violence, 88% from former partners, and 26% from male friends or acquaintances. Of the 72 women, 71% further reported "Countless occasions of violent events," and 36% had been forced to commit criminal acts. Abused women who had been forced to commit criminal acts were significantly more frequently found to be homeless, have reported parental alcohol and/or drug problems, have witnessed domestic violence in childhood, have been victims of sexual violence, have used illicit drugs as a dominant preparation, and have injected illicit drugs. Almost half of the abused women (46%) met criteria for posttraumatic stress disorder (PTSD), where HW showed an almost 4-time higher risk (RR 3.78) than WR. In conclusion there is a particular vulnerability in women with substance abuse to male violence, which has an important impact on their health status. Thus, from a public health perspective, it is suggested that for those women who have experienced male violence, treatment protocols need to include both assessing and addressing the impact of such experience in relation to substance abuse as well as concomitant health concerns.

Past-year nonmedical use of prescription drugs among women on probation and parole: A cross-sectional study

BACKGROUND

Prescription drug-related overdose deaths have increased dramatically in recent years. Women in the justice system experience high rates of drug use, victimization, trauma symptoms, and other health problems and would appear to be at high risk for nonmedical use of prescription drugs (NMUPD). This study will be among the first to describe prevalence and correlates of NMUPD among this population.

METHODS

This cross-sectional study collected data from 406 victimized women on probation and parole between 2010 and 2012. In a multiple logistic regression model, we differentiated women who reported past-year NMUPD from those who did not using demographic, health, other drug use, substance use treatment, and trauma symptom severity variables.

RESULTS

Past-year NMUPD was reported by 26.8% (n = 109) of the overall sample. Women reporting NMUPD were significantly younger and more likely to be white. Past-year use of alcohol (adjusted odds ratio [AOR]: 3.3; 95% confidence interval [CI]: 1.8-6.1), marijuana (AOR: 3.6; 95% CI: 1.8-7.0), methamphetamines (AOR: 6.1; 95% CI: 1.7-21.3), and heroin (AOR: 8.4; 95% CI: 2.0-35.2) were significantly associated with NMUPD. Additionally, each unit increase in the measure assessing bodily pain was associated with a 40% increase (AOR: 1.4; 95% CI: 1.1-1.7) in the odds of NMUPD. Finally, meeting diagnostic criteria for posttraumatic stress disorder almost doubled (AOR: 1.9; 95% CI: 1.1-3.4) the odds of reporting past-year NMUPD.

CONCLUSIONS

Victimized women on probation and parole report high rates of NMUPD, and this behavior intersects with other complex social, behavioral, psychological, and physical needs. The authors recommend increased access to trauma-informed correctional care among women in the justice system.

Does a Primary Health Clinic for Formerly Incarcerated Women Increase Linkage to Care?

OBJECTIVE

This study examined a primary care-based program to address the health needs of women recently released from incarceration by facilitating access to primary medical, mental health, and substance use disorder (SUD) treatment.

STUDY DESIGN

Peer community health workers recruited women released from incarceration within the past 9 months into the Women's Initiative Supporting Health Transitions Clinic (WISH-TC). Located within an urban academic medical center, WISH-TC uses cultural, gender, and trauma-specific strategies grounded in the self-determination theory of motivation. Data abstracted from intake forms and medical charts were examined using bivariate and multivariable regression analyses.

RESULTS

Of the 200 women recruited, 100 attended the program at least once. Most (83.0%) did not have a primary care provider before enrollment. Conditions more prevalent than in the general population included psychiatric disorders (94.0%), substance use (90.0%), intimate partner violence (66.0%), chronic pain (66.0%), and hepatitis C infection (12.0%). Patients received screening and vaccinations (65.9%-87.0%), mental health treatment (91.5%), and SUD treatment (64.0%). Logistic regression revealed that receipt of mental health treatment was associated with number of psychiatric (adjusted odds ratio [AOR], = 4.09; p < .01), and social/behavioral problems (AOR, 2.67; p = .04), and higher median income (AOR, 1.07; p = .05); African American race predicted lower receipt of SUD treatment (AOR, 0.08; p < .01).

CONCLUSIONS

An innovative primary care transitions program successfully helped women recently released from incarceration to receive medical, mental health, and SUD treatment. Primary care settings with specialty programs, including community health workers, may provide a venue to screen, assess, and help recently incarcerated women access needed care.

Childhood Victimization, Attachment, Coping, and Substance Use Among Victimized Women on Probation and Parole

Justice-involved women report high rates of victimization across their life span, and these experiences contribute to their involvement in the criminal justice (CJ) system. Within this population, research has identified an overlap among victimization and substance use, a high-risk coping mechanism. Furthermore, research indicates attachment style is related to coping and high-risk behaviors. Research is needed to understand the relationship among these mechanisms as they relate to intimate partner violence (IPV). To address this gap, this study investigated the relationship between attachment, coping, childhood victimization, substance use, and IPV among 406 victimized women on probation/parole. Results of 6 multivariate regression analyses were statistically significant, accounting for 8%-13% of the variance in IPV. Particularly, childhood sexual victimization and negative coping were significant in all analyses. Findings provide practitioners, administrators, and policymakers information about the specific needs of justice-involved women.

Types and Characteristics of Childhood Sexual Abuse: How Do They Matter in HIV Sexual Risk Behaviors Among Women in Methadone Treatment in New York City?

BACKGROUND

Childhood sexual abuse (CSA) is often considered an important distal factor in HIV sexual risk behaviors; however, there are limited and mixed findings regarding this relationship among women experiencing substance use problems. In addition, research with this population of women has yet to examine differences in observed CSA-HIV sexual risk behaviors relationships by CSA type and characteristics.

OBJECTIVES

This study examines relationships between CSA coding, type, and characteristics and HIV sexual risk behaviors with main intimate partners among a random sample of 390 women in methadone treatment in New York City who completed individual interviews with trained female interviewers.

RESULTS

Findings from logistic regression analyses indicate that CSA predicts substance use with sexual activity, with variations by CSA coding, type, and characteristics; however, the role of CSA is more limited than expected. Having a main partner with HIV risk mediates some relationships between CSA and drinking four or more drinks prior to sex. Intimate partner violence is the most consistent predictor of sexual risk behaviors. Other salient factors include polysubstance use, depression, social support, recent incarceration, relationship characteristics, and HIV status.

CONCLUSIONS/IMPORTANCE

This study contributes to understanding of relationships between CSA and HIV sexual risk behaviors and key correlates associated with HIV sexual risk behaviors among women in methadone treatment. It also highlights the complexity of measuring CSA and its association with sexual risk behaviors and the importance of comprehensive approaches to HIV prevention that address psychological, relational, situational, and substance use experiences associated with sexual risk behaviors among this population.

Targeting the SAVA (Substance Abuse, Violence, and AIDS) Syndemic Among Women and Girls: A Global Review of Epidemiology and Integrated Interventions

OBJECTIVES

Multiple pathways link gender-based violence (GBV) to HIV and other sexually transmitted infections among women and girls who use or inject drugs. The aim of this article is to synthesize global literature that examines associations among the synergistic epidemics of substance abuse, violence, and HIV/AIDS, known as the SAVA syndemic. It also aims to identify a continuum of multilevel integrated interventions that target key SAVA syndemic mechanisms.

METHODS

We conducted a selective search strategy, prioritizing use of meta-analytic epidemiological and intervention studies that address different aspects of the SAVA syndemic among women and girls who use drugs worldwide from 2000 to 2015 using PubMed, MEDLINE, and Google Scholar.

RESULTS

Robust evidence from different countries suggests that GBV significantly increases the risk of HIV and other sexually transmitted infections among women and girls who use drugs. Multiple structural, biological, and behavioral mechanisms link GBV and HIV among women and girls. Emerging research has identified a continuum of brief and extended multilevel GBV prevention and treatment interventions that may be integrated into a continuum of HIV prevention, testing, and treatment interventions to target key SAVA syndemic mechanisms among women and girls who use drugs.

CONCLUSIONS

There remain significant methodological and geographical gaps in epidemiological and intervention research on the SAVA syndemic, particularly in low- and middle-income countries. This global review underscores the need to advance a continuum of multilevel integrated interventions that target salient mechanisms of the SAVA syndemic, especially for adolescent girls, young women, and transgender women who use drugs.

Psychological distress among victimized women on probation and parole: A latent class analysis

Latent class analysis was used to identify subgroups of victimized women (N = 406) on probation and parole differentiated by levels of general psychological distress. The 9 primary symptom dimensions from the Brief Symptom Inventory (BSI) were used individually as latent class indicators (Derogatis, 1993). Results identified 3 classes of women characterized by increasing levels of psychological distress; classes were further differentiated by posttraumatic stress disorder symptoms, cumulative victimization, substance use and other domains of psychosocial functioning (i.e., sociodemographic characteristics; informal social support and formal service utilization; perceived life stress; and resource loss). The present research was effective in uncovering important heterogeneity in psychological distress using a highly reliable and easily accessible measure of general psychological distress. Differentiating levels of psychological distress and associated patterns of psychosocial risk can be used to develop intervention strategies targeting the needs of different subgroups of women. Implications for treatment and future research are presented.

Childhood victimization, attachment, psychological distress, and substance use among women on probation and parole

The present analysis was guided by a gendered pathways-based theoretical model and examined relationships between childhood victimization and current attachment, psychological distress, and substance use among 406 women with histories of victimization who were on probation and parole in an urban Kentucky county. Structural equation modeling examined relationships among childhood victimization, attachment, psychological distress, and substance use. Additionally, we examined the mediational role that attachment plays in relationships between childhood victimization and both psychological distress and substance use. The data fit the models properly. Psychological distress was significantly predicted by childhood victimization, and adult attachment partially mediated this relationship. Childhood victimization did not significantly predict substance use; however, attachment did. The findings suggest that attachment may be an important factor to further understand and address in relation to psychological distress and substance use among women with histories of victimization who are involved in the criminal justice system.

Prolonged Exposure for Treating PTSD Among Female Methadone Patients Who Were Survivors of Sexual Abuse in Israel

The aims of this pilot study were: (a) to test the feasibility of prolonged exposure (PE) therapy conducted by a social worker staff on female patients in methadone program clinics who were survivors of child sexual abuse or rape and (b) to examine preliminary outcomes of PE on posttraumatic stress disorder (PTSD), depression, and illicit drug use at pre- and posttreatment, and up to 12-month follow-ups. Twelve female methadone patients who were survivors of child sexual abuse or rape diagnosed with PTSD were enrolled in 13-19 weekly individual PE sessions. Assessments were conducted at pre-, mid-, and posttreatment, as well as at 3, 6, and 12-month follow-ups. The treatment outcomes measures included PTSD symptoms, depressive symptoms, and illicit drug use. Ten of the 12 study patients completed treatment. PTSD and depressive symptoms showed significant reduction. No relapse to illicit drug use was detected. These preliminary results suggest that PE may be delivered by methadone social workers with successful outcomes. Further research should test the efficacy of PE among methadone patients in a randomized control trial with standard care as the control condition.

Child abuse and neglect and intimate partner violence victimization and perpetration: a prospective investigation

This paper describes the extent to which abused and neglected children report intimate partner violence (IPV) victimization and perpetration when followed up into middle adulthood. Using data from a prospective cohort design study, children (ages 0-11) with documented histories of physical and sexual abuse and/or neglect (n=497) were matched with children without such histories (n=395) and assessed in adulthood (Mage=39.5). Prevalence, number, and variety of four types of IPV (psychological abuse, physical violence, sexual violence, and injury) were measured. Over 80% of both groups - childhood abuse and neglect (CAN) and controls - reported some form of IPV victimization during the past year (most commonly psychological abuse) and about 75% of both groups reported perpetration of IPV toward their partner. Controlling for age, sex, and race, overall CAN [adjusted odds ratio (AOR)=1.60, 95% CI [1.03, 2.49]], physical abuse (AOR=2.52, 95% CI [1.17, 5.40]), and neglect (AOR=1.64, 95% CI [1.04, 2.59]) predicted increased risk for being victimized by a partner via physical injury. CAN and neglect also predicted being victimized by a greater number and variety of IPV acts. CAN and control groups did not differ in reports of perpetration of IPV, although neglect predicted greater likelihood of perpetrating physical injury to a partner, compared to controls. Abused/neglected females were more likely to report being injured by their partner, whereas maltreated males did not. This study found that child maltreatment increases risk for the most serious form of IPV involving physical injury. Increased attention should be paid to IPV (victimization and perpetration) in individuals with histories of neglect.

When higher doses in opioid replacement treatment are still inadequate - association to multidimensional illness severity: a cohort study

BACKGROUND

Opioid replacement treatment (ORT) with methadone is regarded as gold standard in the treatment of opioid addiction. Treatment doses of 60 mg methadone per day and above are associated with better treatment retention and reduction in the use of heroin and cocaine. However, an absolute dose level cannot function as parameter for adequate dosing. This study aims to determine dose adequacy in a sample of patients on stable methadone treatment, and to relate dose adequacy to disease severity.

METHODS

This study was designed as open prospective cohort study over 12 months, with baseline data reported here. Patients on stable substitution treatment with methadone (Eptadone®) were consecutively included. Medical and socio-demographic data were gathered and the instruments Opiate Dosage Adequacy Scale (ODAS), European Addiction Severity Index (EuropASI) and the Derogatis Interview for Sexual Functioning - Self Report (DISF-SR) were applied.

RESULTS

Five hundred and sixteen subjects, who received on average 60.3 (±30.4) mg methadone per day, were included. According to ODAS, 40.6% suffered from an inadequate dosing, and 59.4% had an adequate dose. Patients with an adequate dose received on average 57.8 (±27.5) mg methadone per day, whilst patients with an inadequate dose received on average 70.6 (±33.0) mg per day. The frequencies of patients with methadone doses of less than 60 mg per were 45.4% in the inadequate and 60.6% in the adequate group. The inadequate group suffered from a statistically significant higher burden of addiction related problems in all EuropASI domains. Sexual functioning did not differ by adequacy group, but women suffered from more pronounced sexual dysfunction as compared to men.

CONCLUSION

A high frequency of inadequate dosing was found in this sample of patients on ORT. Higher disease severity should alert for possible need of even higher methadone doses. The tendency to low methadone doses warrants further research in the treatment system. Higher methadone doses are not related to increased sexual dysfunction. Sexual dysfunction, especially in women, should be considered in treatment.

Meeting health and psychological needs of women in drug treatment court

We explored healthcare-related experiences of women drug court participants through combining context from the socio-ecological model with motivation needs for health behavior as indicated by self-determination theory. Five focus groups with 8 women drug court participants, 8 court staff, and 9 community service providers were examined using qualitative framework analysis. Themes emerged across the socio-ecological model and were cross-mapped with self-determination theory-defined motivation needs for autonomy, relatedness, and competence. Socio-ecological levels contained experiences either supporting or eroding women's motivation needs: (1) intrapersonal challenges participants termed an "evil cycle" of relapse, recidivism, trauma, and life challenges; (2) interpersonal context of parenting and stigma involving features of this "evil cycle"; (3) institutions with logistical barriers to legal and medical assistance; (4) community resources inadequate to support living and employment needs. Self-determination theory helps explain motivation required to address the women's healthcare needs and multiple demands at all levels of the socio-ecological model.

Sex work and its associations with alcohol and methamphetamine use among female bar and spa workers in the Philippines

To assess the prevalence of sex work and its associations with substance use among female bar/spa workers in the Philippines (N = 498), workers from 54 bar or spa venues in Metro Manila (2009-2010) were surveyed on demographics, drug/alcohol use, abuse history, and sex work. Their median age was 23 years and 35% engaged in sex work. Sex work was independently associated with methamphetamine use (19% vs 4%; adjusted odds ratio [AOR] =2.9, 95% confidence interval [CI] = 1.3-6.2), alcohol use with patrons (49% vs. 27%; AOR = 1.9, 95% CI = 1.1-3.4), and alcohol intoxication during sex (50% vs. 24%; AOR = 2.0, 95% CI = 1.2-3.5), but inversely associated with daily alcohol use (13% vs. 16%; AOR = 0.2, 95% CI = 0.1-0.5). Additional significant covariates included sexual abuse history, younger age, and not having a higher education. Findings suggest that interventions with sex workers in bars and spas should focus on methamphetamine use, alcohol use contexts, and violence victimization, to better meet the needs of this population.

Developing effective health interventions for women who inject drugs: key areas and recommendations for program development and policy

Women who inject drugs face multiple gender-specific health risks and barriers to healthcare access. These gendered factors may contribute to elevated rates of HIV for this population. Though few countries systematically collect gender-disaggregated data related to injecting drug use, evidence indicates that there are large populations of women who inject drugs and who are in need of improved health services, including HIV prevention. Research on the effectiveness of interventions specifically tailored for women who inject drugs, along with the experience of programs working with this subpopulation, suggests that HIV risk practices need to be addressed within the larger context of women's lives. Multifaceted interventions that address relationship dynamics, housing, employment, and the needs of children may have more success in reducing risky practices than interventions that focus exclusively on injecting practices and condom use. Improved sexual and reproductive healthcare for women who use drugs is an area in need of development and should be better integrated into basic harm reduction programs.