Developing an Integrated Violence Prevention for Men and Women in Treatment for Substance Use Disorders

Testing a new model of telehealth-delivered treatment for primary care patients with alcohol use disorder: A randomized controlled trial protocol

BACKGROUND

The majority of adults suffering from alcohol use disorders (AUD) do not receive treatment. To address this gap in care, we must develop new models to increase identification, engagement and delivery of accessible and effective treatment. This paper describes the protocol for a randomized controlled trial (RCT) testing a novel telehealth treatment model for primary care patients with untreated AUD.

METHODS

We aim to recruit 300 adults across 2 healthcare systems for this two-arm RCT. Participants, initially identified for recruitment based on AUD-related indicators in their electronic health record (EHR), are RCT-eligible if they meet AUD criteria (mild, moderate, severe), report ≥ 3 drinking days/week in past 30 days, and have not received AUD psychotherapy in the past 90 days. Participants are randomized to an intervention or enhanced usual care control (EUC) condition, both individually-delivered. The intervention includes a telephone-delivered motivational interviewing (MI) engagement session and 8 sessions of MI-Cognitive Behavioral Therapy (MI-CBT). EUC involves AUD psychoeducation, advice to reduce drinking and seek treatment, and provision of community resources. Outcomes will be measured at 3-, 6-, and 12-months; primary outcomes include: AUD psychotherapy initiation and engagement (within the study and external community) and alcohol consumption (percent drinking days and heavy drinking days).

CONCLUSIONS

This study addresses whether proactive patient identification and engagement and delivery of patient-centered telehealth psychotherapy to patients with untreated AUD is effective in increasing treatment use and improving alcohol outcomes. If effective, this could be a highly scalable model for reducing the public health impact of AUD.

TRIAL REGISTRATION

ClinicalTrials.gov # NCT05410561. University of Michigan HUM00204315. Ann Arbor VA IRB #1655886.

Histories of violence among clients seeking substance use disorder treatment: a systematic mapping review

Introduction

There is a limited literature base regarding the intersection of drug and alcohol treatment, violence, and trauma. While research substantiates that exposure to violence and trauma impacts the propensity to misuse substances, the conceptualization in clinical trials and practice has largely been narrow and gendered, referring only to intimate partner or domestic violence. Our systematic mapping review explored a more inclusive and expansive review of survivors of and perpetrators of violence and trauma (e.g., intimate partner violence, sexual assault, stalking, child abuse, political and community violence, criminal violence, micro violence, structural violence, and oppression) to establish: 1) the types of treatment settings included in intervention studies, 2) the common indicators of success or common outcomes recorded, and 3) understanding who is seeking treatment for drug and alcohol use with histories of violence.

Methods

A systematic mapping review was conducted to identify any peer-reviewed articles published from 2011 to 2022. The Web of Science database was searched using a broad set of Boolean search terms related to violence, substance use disorders, and treatment. Over 8,800 records were identified from the systematic review with a total of 48 articles meeting inclusion criteria.

Results

Most studies in this review included populations reporting perpetration of violence (n=23, 48%) versus participants reporting survival of trauma/violence (n=17, 35%). Results also indicated female identifying populations (n=19; 40%) were predominantly served, were treated in the US (n=33; 69%) and seen in an outpatient setting (n=24; 50%). Authors also were attentive to studies that included sexual and gender minorities and discovered only three studies (6%) explicitly acknowledging inclusion of transgender participants or participants in relationship with partners of the same sex; three more studies (6%) were focused on participants with histories of or engaging in sex work.

Discussion

This review outlines treatment and research implications directly situated in the gap of service delivery found in this review. Specifically, the results elucidate the impact on minoritized and excluded identities based on gender, sexual preference, criminal legal status and directions for research and treatment to increase inclusion, representation, and equity across research and treatment settings.

Prevention interventions for interpersonal violence occurring under the influence of alcohol: A mixed method systematic review

AIMS

To (a) explore risk indicators related to interpersonal violence occurring under the influence of alcohol and to (b) search for interventions addressed towards violence perpetrators to prevent violence occurring under the influence of alcohol.

DESIGN

Mixed method systematic review. This study has been registered in the International Prospective Register of Systematic Reviews with register number CRD42021217848.

DATA SOURCES

A systematic search was conducted on PubMed, CINAHL, PsycINFO and Scopus in October 2021.

REVIEW METHODS

Two researchers independently examined 1076 papers following the inclusion criteria. After three rounds of selection (title, abstract and full text), the quality and bias assessments were conducted independently by two reviewers. The data were analysed with inductive and deductive content analyses.

RESULTS

Of the 1076 papers retrieved, 16 papers were eligible for inclusion, addressing 13 different interventions. Interventions were divided into three types (individual-, group- and family-level) and were constructed on several background frameworks, with cognitive behavioural therapy being the most common framework. Family-level interventions seemed to yield the most effective results. Violence occurring under the influence of alcohol was mostly researched as men being the perpetrators and women being the victims of violence. Several indicators that increased the risk of violence victimization or perpetration, such as trait jealousy and disparity in education, were identified.

CONCLUSION

Interventions emerging from the systematic review were heterogenous, and the outcomes of the interventions were versatile. The disparity between interventions and outcome measures made it challenging to reliably compare the effectiveness between interventions. Using standardized outcome measure instruments and unifying research on interventions are needed to reliably assess the effectiveness of different interventions.

Substance use related violent deaths among racial/ethnic groups in the United States

While prior research highlights the overlap of substance use and violent death, few examine this overlap among different racial/ethnic groups or how patterns change over time. This study examines how substance use related deaths differ by racial/ethnic groups in the United States. We use data from the National Violent Death Reporting System (NVDRS), which includes violent deaths from 43 states in the U.S., collected for the decade between 2009 and 2019 (N = 226,459). Fixed-effects multivariate models examined whether race/ethnicity was associated with substance use-related death over time, controlling for additional demographic and clinical factors. Results showed a significantly larger rate of increase over time for African American and Hispanic (any race) persons compared to White non-Hispanic persons for most types of substance use-related deaths. While current rates of substance use may show little variability between African American, Hispanic, and White non-Hispanic individuals, this research suggests that the consequences for substance use, including death, may be disproportional.

Gewalttätigkeiten in Partnerschaften – Männer und Frauen mit Suchtproblemen als Opfer und Täter/Täterinnen

In diesem Beitrag geht es um Gewalttätigkeiten in Partnerschaften und den Zusammenhang mit dem Konsum bzw. Missbrauch von Alkohol und anderen (stimulierenden) psychoaktiven Substanzen. Hellfelddaten, die vom Bundeskriminalamt zusammengestellt werden, belegen, dass rund ¼ derjenigen, die wegen Gewalttätigkeiten in Partnerschaften angezeigt werden, unter dem Einfluss von Alkohol stehen; die Mehrzahl von ihnen ist männlich, die Minderheit weiblich. Jedoch belegen Befragungsdaten (sog. Dunkelfelddaten), dass das Ausmaß der Partnerschaftsgewalt viel höher ist und viel höhere Zahlen von Täter:innen und Opfern existieren. Zudem zeigen Studien, die mit den Conflict Tactics Scales durchgeführt worden sind, dass das Aggressionsniveau von Männern und Frauen sich wenig voneinander unterscheidet. Das gilt allerdings nicht für sexualisierte Gewalt, Frauen sind fast immer die Opfer von sexualisierter Gewalt. Zusammengefasst kann festgehalten werden, dass Männer und Frauen sich in etwa gleicher Häufigkeit sowohl „nüchtern“ als auch unter dem Einfluss von psychoaktiven Substanzen in leichte aggressive Auseinandersetzungen einlassen, aber es sind vor allem Männer, die darüber hinaus gehen, insbesondere hinsichtlich sexueller Gewalt. Schätzungen auf der Basis von Behandlungsdaten weisen darauf hin, dass rund 2/3 der Frauen, die in einer Suchtbehandlung sind, Opfer von Partnerschaftsgewalt sind. Eine kleinere Gruppe von Frauen ist in kleinere aggressive Auseinandersetzungen involviert und einige wenige Frauen sind selbst gewalttätig. Diese Gruppen von Frauen benötigen unterschiedliche Hilfsprogramme ebenso wie Männer als Gewalttäter oder Opfer, damit sie sich entweder gegen Gewalt in Partnerschaften wehren können oder ihren Ärger und ihre Impulsivität kontrollieren lernen.

Identification of Domestic Violence Service Needs Among Child Welfare-Involved Parents With Substance Use Disorders: A Gender-Stratified Analysis

The current study examined the prevalence and associations of a need for domestic violence services among child welfare-involved mothers and fathers with substance use disorders. Data were drawn from 2,231 child welfare-involved parents in Illinois with an identified substance use disorder. Approximately 42% of mothers and 33% of fathers with a substance use disorder had a concurrent need for domestic violence services. The sample was stratified by gender and logistic regression models were fit to determine the adjusted odds of an identified need for domestic violence services. For both mothers and fathers, the strongest association was an additional need for mental health services. Age, education status, alcohol use, marijuana use, and a reported history of physical violence victimization were also associated with a need for domestic violence services among mothers, while race, age, marital status, annual income, alcohol use, cocaine use, and a reported history of physical violence perpetration were associated with a need for domestic violence services among fathers. The findings of this study make clear that domestic violence is a commonly co-occurring service need for child welfare-involved parents with identified substance use disorders, and that associations with this need vary by gender.

Relationships between insomnia and alcohol and cocaine use frequency with aggression among veterans engaged in substance use treatment

BACKGROUND

Veterans with substance use problems have rates of partner and non-partner violence that typically exceed the general population. Sleep problems may exacerbate violence and maintain addictive behaviors in non-veterans, but requires study in veterans. Therefore, we examine the interrelationships between substance use, insomnia, and violence in veterans.

METHODS

Veterans (N = 762) screened for a randomized controlled trial at veterans affairs mental health and substance use clinics. Participants completed modified Conflict Tactics Scales to quantify past-year violence and the Insomnia Symptom Questionnaire to assess sleep disturbance. We evaluated associations between substance use and sleep in predicting the target of aggression (partner or non-partner) and degree of violence (aggression or injury) using binomial logistic regressions.

RESULTS

Half of participants endorsed symptoms suggestive of insomnia, 23.2% endorsed physical aggression toward partners (PA-P) and 33.9% non-partners (PA-NP), and 9.7% endorsed physical injury of partners (PI-P) and 17.6% of non-partners (PI-NP). Regressions revealed significant models for PA-P, PA-NP, and PI-NP, whereas the PI-P model was not significant. PA-P was higher among non-Caucasian race and older veterans. PA-NP was more common in those with insomnia and increased with frequency of cocaine use. Insomnia moderated the relationship between cocaine use and PA-NP; there was a weaker relationship between cocaine use and PA-NP in those with insomnia. PI-NP was more common with higher frequency of alcohol and cocaine use, and in those with insomnia.

CONCLUSIONS

This study finds sleep disturbances are meaningful predictors of violence among veterans with differential relationships with aggression severity, victims, and substance use concurrence.

Extending the ACEs Framework: Examining the Relations Between Childhood Abuse and Later Victimization and Perpetration With College Men

Research has revealed that forms of violence are interconnected, but less work focuses on the interconnection of victimization and perpetration, particularly with men. Subsequently, our understanding of the complexities of violence exposure in men's lives and related policies and treatments remains limited. The present study utilizes a sample of at-risk for violence involvement, college men, to examine the relationships between childhood victimization, adulthood victimization, and adulthood perpetration. Participants are 423 college men receiving course credit who completed a battery of standardized questionnaires via an anonymous web survey. Logistic regression is used. Results indicate that 27% of the men report polyperpetration (two or more types of perpetration), 43.5% report polyvictimization (two or more types of victimization), and 60% report experiencing both forms of victimization and perpetration in the past year. Childhood physical abuse has predictive power for perpetration (psychological aggression and polyperpetration) and victimization (sexual violence, psychological aggression, and polyvictimization) for the men in the past year. Childhood sexual abuse has strong predictive power for perpetration (physical violence, sexual violence, and polyperpetration) and victimization (physical violence and sexual violence) with the men in the past year. Finally, emotional abuse has predictive power for victimization (physical violence and psychological aggression), but not perpetration, for the men in the past year. Developmental psychopathology and the adverse childhood experiences frameworks are used to posit potential pathways explaining the relation between childhood abuse and the overlap between victimization and perpetration in adulthood for men. Implications of this study include the use of trauma-informed models of care with men and expanding the scope of study to examine experiences of both victimization and perpetration, and various types of violence, among men.

Psychological therapies for women who experience intimate partner violence

BACKGROUND

Intimate partner violence (IPV) against women is prevalent and strongly associated with mental health problems. Women experiencing IPV attend health services frequently for mental health problems. The World Health Organization recommends that women who have experienced IPV and have a mental health diagnosis should receive evidence-based mental health treatments. However, it is not known if psychological therapies work for women in the context of IPV and whether they cause harm.

OBJECTIVES

To assess the effectiveness of psychological therapies for women who experience IPV on the primary outcomes of depression, self-efficacy and an indicator of harm (dropouts) at six- to 12-months' follow-up, and on secondary outcomes of other mental health symptoms, anxiety, quality of life, re-exposure to IPV, safety planning and behaviours, use of healthcare and IPV services, and social support.

SEARCH METHODS

We searched the Cochrane Common Mental Disorders Controlled Trials Register (CCMDCTR), CENTRAL, MEDLINE, Embase, CINAHL, PsycINFO, and three other databases, to the end of October 2019. We also searched international trials registries to identify unpublished or ongoing trials and handsearched selected journals, reference lists of included trials and grey literature.

SELECTION CRITERIA

We included randomised controlled trials (RCTs), quasi-RCTs, cluster-RCTs and cross-over trials of psychological therapies with women aged 16 years and older who self-reported recent or lifetime experience of IPV. We included trials if women also experienced co-existing mental health diagnoses or substance abuse issues, or both. Psychological therapies included a wide range of interventions that targeted cognition, motivation and behaviour compared with usual care, no treatment, delayed or minimal interventions. We classified psychological therapies according to Cochrane Common Mental Disorders's psychological therapies list.

DATA COLLECTION AND ANALYSIS

Two review authors extracted data and undertook 'Risk of Bias' assessment. Treatment effects were compared between experimental and comparator interventions at short-term (up to six months post-baseline), medium-term (six to under 12 months, primary outcome time point), and long-term follow-up (12 months and above). We used standardised mean difference (SMD) for continuous and odds ratio (OR) for dichotomous outcomes, and used random-effects meta-analysis, due to high heterogeneity across trials.

MAIN RESULTS

We included 33 psychological trials involving 5517 women randomly assigned to experimental (2798 women, 51%) and comparator interventions (2719 women, 49%). Psychological therapies included 11 integrative therapies, nine humanistic therapies, six cognitive behavioural therapy, four third-wave cognitive behavioural therapies and three other psychologically-orientated interventions. There were no trials classified as psychodynamic therapies. Most trials were from high-income countries (19 in USA, three in Iran, two each in Australia and Greece, and one trial each in China, India, Kenya, Nigeria, Pakistan, Spain and UK), among women recruited from healthcare, community, shelter or refuge settings, or a combination of any or all of these. Psychological therapies were mostly delivered face-to-face (28 trials), but varied by length of treatment (two to 50 sessions) and staff delivering therapies (social workers, nurses, psychologists, community health workers, family doctors, researchers). The average sample size was 82 women (14 to 479), aged 37 years on average, and 66% were unemployed. Half of the women were married or living with a partner and just over half of the participants had experienced IPV in the last 12 months (17 trials), 6% in the past two years (two trials) and 42% during their lifetime (14 trials). Whilst 20 trials (61%) described reliable low-risk random-sampling strategies, only 12 trials (36%) described reliable procedures to conceal the allocation of participant status. While 19 trials measured women's depression, only four trials measured depression as a continuous outcome at medium-term follow-up. These showed a probable beneficial effect of psychological therapies in reducing depression (SMD -0.24, 95% CI -0.47 to -0.01; four trials, 600 women; moderate-certainty evidence). However, for self-efficacy, there may be no evidence of a difference between groups (SMD -0.12, 95% CI -0.33 to 0.09; one trial with medium-term follow-up data, 346 women; low-certainty evidence). Further, there may be no difference between the number of women who dropped out from the experimental or comparator intervention groups, an indicator of no harm (OR 1.04, 95% CI 0.75 to 1.44; five trials with medium-term follow-up data, 840 women; low-certainty evidence). Although no trials reported adverse events from psychological therapies or participation in the trial, only one trial measured harm outcomes using a validated scale. For secondary outcomes, trials measured anxiety only at short-term follow-up, showing that psychological therapies may reduce anxiety symptoms (SMD -0.96, 95% CI -1.29 to -0.63; four trials, 158 women; low-certainty evidence). However, within medium-term follow-up, low-certainty evidence revealed that there may be no evidence between groups for the outcomes safety planning (SMD 0.04, 95% CI -0.18 to 0.25; one trial, 337 women), post-traumatic stress disorder (SMD -0.24, 95% CI -0.54 to 0.06; four trials, 484 women) or re-exposure to any form of IPV (SMD 0.03, 95% CI -0.14 to 0.2; two trials, 547 women).

AUTHORS' CONCLUSIONS

There is evidence that for women who experience IPV, psychological therapies probably reduce depression and may reduce anxiety. However, we are uncertain whether psychological therapies improve other outcomes (self-efficacy, post-traumatic stress disorder, re-exposure to IPV, safety planning) and there are limited data on harm. Thus, while psychological therapies probably improve emotional health, it is unclear if women's ongoing needs for safety, support and holistic healing from complex trauma are addressed by this approach. There is a need for more interventions focused on trauma approaches and more rigorous trials (with consistent outcomes at similar follow-up time points), as we were unable to synthesise much of the research.

An investigation of the knowledge of intimate partner violence among clinical staff working with male substance misusers

Purpose

The purpose of this paper is to describe a Service Improvement Project aimed at assessing the level of knowledge of intimate partner violence (IPV) of clinical staff working in Community Drug and Alcohol Services (CDAS) in four boroughs of South London.

Design/methodology/approach

Clinical staff (n=90) completed a survey which was based on the Capability Framework (Hughes et al., 2015), developed to describe the key capabilities required to work with men who misuse drug and alcohol and perpetrate IPV. Two separate surveys were prepared for clinical (core) staff (n=76) and for manager (senior) staff (n=14).

Findings

The Capability Framework provided a useful structure for identifying key strengths and gaps in knowledge and skills related to substance use and IPV treatment in frontline CDAS staff. Significant strengths which emerged in the “core staff” survey related to the importance of assessing IPV and being empathic. Gaps related to the confidence in working with these issues and receiving support. Significant strengths which emerged in the “senior staff” survey related to the availability of supervision, information and training on IPV. Gaps related to using the Capability Framework and discussing IPV in supervision.

Originality/value

Findings have important implications for the development of training addressing gaps in current knowledge and skills required when working with IPV in the context of drug and alcohol misuse.

Wireless Participant Incentives Using Reloadable Bank Cards to Increase Clinical Trial Retention With Abused Women Drinkers: A Natural Experiment

Retaining participants in longitudinal studies is a unique methodological challenge in many areas of investigation, and specifically for researchers aiming to identify effective interventions for women experiencing intimate partner violence (IPV). Individuals in abusive relationships are often transient and have logistical, confidentiality, and safety concerns that limit future contact. A natural experiment occurred during a large randomized clinical trial enrolling women in abusive relationships who were also heavy drinkers, which allowed for the comparison of two incentive methods to promote longitudinal retention: cash payment versus reloadable wireless bank cards. In all, 600 patients were enrolled in the overall trial, which aimed to incentivize participants using a reloadable bank card system to promote the completion of 11 weekly interactive voice response system (IVRS) phone surveys and 3-, 6-, and 12-month follow-up phone or in person interviews. The first 145 participants were paid with cash as a result of logistical delays in setting up the bank card system. At 12 weeks, participants receiving the bank card incentive completed significantly more IVRS phone surveys, odds ratio (OR) = 2.4, 95% confidence interval (CI) = [0.01, 1.69]. There were no significant differences between the two groups related to satisfaction or safety and/or privacy. The bank card system delivered lower administrative burden for tracking payments for study staff. Based on these and other results, our large medical research university is implementing reloadable bank card as the preferred method of participant incentive payments.

Gender-specific predictors of methadone treatment outcomes among African Americans at an urban clinic

Background: African American patients with opioid use disorder (OUD) have demonstrated poorer methadone maintenance treatment (MMT) outcomes compared with white patients. This issue is further complicated in urban settings, where African Americans experience high rates of poverty and publicly funded treatment. Despite interrelated factors that disadvantage African Americans, the literature focusing on this population is scant. To address this shortcoming, we conducted the first investigation of gender differences and gender-specific MMT outcome predictors among African Americans (or any racial minority population). This study provides gender-specific findings to improve African American MMT outcomes. Methods: We studied 211 African American patients (male: n = 137, 64.9%) at an urban, university-affiliated MMT clinic. We used existing intake data to assess baseline demographic, substance use, mental health, and interpersonal factors. Primary outcomes were 3-month drug⁺ (positive) urine drug screen (UDS) results and treatment retention. Results: Women were more likely (than men) to endorse histories of interpersonal violence, substance abuse in their social network, and mental health problems. Men reported a greater likelihood (than women) for early opioid-use onset and a lack of prior MMT. There were no gender differences in 3-month drug⁺ UDS or treatment retention. In multivariable analyses among women, no baseline factors predicted 3-month opioid⁺ UDS and physical abuse history predicted a higher proportion of 3-month cocaine⁺ UDS. Among men, primary injection opioid use and older age best predicted a higher proportion of 3-month cocaine⁺ UDS and parent substance abuse predicted shorter retention. In both gender-stratified analyses, higher proportions of 3-month opioid⁺ UDS and cocaine⁺ UDS predicted shorter retention. Conclusions: This study offers an analysis of gender differences in risk factors, MMT outcomes, and gender-specific predictors among African American patients. MMT clinics should tailor assessment and treatment protocols to address gender-specific needs.

A Latent Profile Analysis of Aggression and Victimization Across Relationship Types Among Veterans Who Use Substances

OBJECTIVE

This study examined patterns of violence victimization and aggression in both intimate partner and nonpartner relationships among U.S. military veterans using latent profile analysis to identify subtypes of violence involvement.

METHOD

Participants were 839 substance use treatment-seeking veterans (93% male) from a large Veterans Affairs Medical Center who completed screening measures for a randomized controlled trial.

RESULTS

Past-year violence involvement, including both intimate partner violence (IPV) and nonpartner violence (NPV), was common in the sample, although NPV occurred at somewhat higher rates. When we included either IPV or NPV aggression or victimization, more than 40% reported involvement with physical violence, 30% with violence involving injury, and 86% with psychological aggression. Latent profile analysis including both aggression and victimization in partner and nonpartner relationships indicated a four-profile solution: no/low violence (NLV; n = 377), predominantly IPV (n = 219), predominantly NPV (n = 134), and high general violence (HGV; n = 109). Multinomial logistic regression analyses revealed that, compared with the NLV group, the remaining three groups differed in age, cocaine use, posttraumatic stress disorder (PTSD) symptoms, and legal involvement. Legal issues appeared to differentiate the profiles most, with the predominantly NPV and HGV profiles reporting more instances of driving under the influence and the HGV profile reporting legal problems related to aggression.

CONCLUSIONS

IPV and NPV are fairly common among veterans seeking substance use treatment. The clinical characteristics of violence profiles indicate that cocaine use, PTSD symptoms, and legal involvement are treatment needs that vary with violence profile and may be useful for clinical decision making.