SAN DIEGO ― Substance use coercion, or forced drug use, by an intimate partner has largely gone undetected by addiction psychiatrists, but a recent survey shows the practice is "disturbingly common."
Results of a survey conducted by the National Domestic Violence Hotline that included more than 3000 callers revealed that 43% of respondents had experienced some type of substance use coercion by their partner. Coercion tactics included forced drug use, efforts to sabotage substance use recovery, and threats to report respondents to the authorities.
Approximately 25% of callers reported that they used substances to reduce the physical pain of partner abuse, and a similar proportion reported that they were afraid to call the police for help.
"There are high rates of substance use among people who experience intimate partner violence [IPV] and high rates of intimate partner violence among people accessing substance use disorder treatment programs, but there hasn't been much research on substance use coercion," study investigator Carole L. Warshaw, MD, director, National Center on Domestic Violence, Trauma and Mental Health, Chicago, Illinois, told Medscape Medical News.
In fact, the first thought many people have when they hear the words "substance use coercion" is forced compliance with addiction treatment, Warshaw said.
"They think coercion means forcing someone to undergo treatment, and when we did a literature review, that's what came up. But there has not been as much awareness about this particular type of abuse, where someone deliberately tries to get you to use, to the point where you become physiologically dependent and develop a substance use disorder," she added.
The findings were presented here at the American Academy of Addiction Psychiatry (AAAP) 30th Annual Meeting.
First Large-Scale Study
Previous research shows that IPV increases victims' risk of developing a range of mental health disorders, including depression, posttraumatic stress disorder (PTSD), and suicidality, as well as chronic pain and substance use.
Although "for decades," survivors have reported coercive tactics by intimate partners targeted toward their substance abuse as part of a broader pattern of control, the current survey provides "the first large-scale quantitative data on the issue," the investigators note.
The Substance Use Coercion Survey identified 3224 women during a 6-week period who were victims or survivors of domestic violence. The women had completed the service portion of their call and were not in crisis at the time of the interview.
The survey results revealed the following:
26% of respondents said they used substances to reduce the pain of partner abuse.
27% reported they felt pressured or forced to use alcohol or other drugs or were made to use more than they wanted.
15.2% reported seeking help for substance use; of these, 60.1% said their partner or ex-partner had tried to prevent or discourage them from getting help.
37.5% said their partner or ex-partner threatened to report alcohol use or other drug use to someone in authority to keep them from getting something they wanted or needed.
24.4% reported they were afraid to call the police for help because the partner said that they wouldn't be believed because they use drugs or that they would be arrested for being under the influence.
Substance use coercion undermines a partner's sanity and sobriety, controls their ability to engage in treatment, sabotages recovery efforts, discredits them with potential sources of protection and support, jeopardizes child custody, and exploits an individual's substance use for personal or financial gain.
"When you think of the drivers of the opioid epidemic, overprescribing and the pharmaceutical industry come to mind, but people don't think about gender-based violence, either by an intimate partner or a human sex trafficker, as a driver," Warshaw said.
Women are the most frequently affected, she said, but she said that the phenomenon also occurs in men.
"We know women are more likely to experience depression, PTSD, and anxiety, more likely to experience personal violence, and more likely to experience chronic pain. They are also more likely to be overprescribed opioids for longer periods, to become addicted more quickly, and to have use initiated by a romantic partner.
"All of this is amplified in the context of IPV where a woman is deliberately pressured, coerced, or forced into using drugs as a tactic of control and then control their partner's supply to keep them from leaving in order to avoid withdrawal," Warshaw said.
Verbal Threats, Physical Violence
The investigators found that abusers employ a wide range of threats, including threats of loss of child custody, financial support, and housing, as well as physical violence and drugging victims without their knowledge, said Warshaw.
Abusive partners also frequently attempt to interfere with their partner's recovery by employing a variety of tactics to prevent them from receiving treatment. These include withholding transportation or childcare, threatening their children, or physically holding them hostage.
"Eventually," said Warshaw, "substance use treatment providers think the person isn't serious about treatment and give up on them."
Women have also reported that their intimate partners have forced them to use drugs and have videotaped them and then threatened to report them to child protective services.
"People who perpetrate IPV try to control their partners in any way they can," said Warshaw.
Other tactics used by intimate partners include planting drug paraphernalia and then calling law enforcement. Some victims have reported being forced to use dirty needles and, as a result, have developed serious intravenous infections.
"Once someone has a criminal record, that gives their abusive partner an additional control, because they can hold the threat of reporting them to a parole or probation officer over them," she said.
"People who abuse their partners know that threatening a woman with loss of custody of children is one of the most powerful tactics of control. For example, if a woman is pregnant, a partner can force her to use and then report her. This in turn can lead to a positive urine drug screen and put her at risk for loss of custody," Warshaw added.
Step One: Be Aware
The first step in addressing substance use coercion is to recognize that it may be a factor in a patient's substance use and that it may affect their ability to engage in treatment and undermine recovery. Providers should consider IPV and substance use coercion if a patient stops coming for treatment, experiences relapse, or overdoses.
"Providers should always ask about substance use coercion as part of their substance use histories. They should have conversations about how this is impacting their patients, and then they should strategize with them about ways to address the problem. Even if the person in front of you is committed to their recovery, there might be someone at home sabotaging their best efforts," Warshaw said.
"My hope is that people recognize that this is an important issue and re-think how they are practicing, that they consider the ways that substance use coercion can create barriers to treatment, and that they factor substance use coercion into their assessments and treatment planning."
Practitioners should consider partnerships with local domestic violence programs and information about additional community resources such as support groups as part of a comprehensive treatment approach, she added.
Treatment providers can also access a tool kit on strategies for addressing substance use coercion in clinical practice, which is available on the National Center on Domestic Violence, Trauma and Mental Health website.
A "Critical Issue"
Commenting on the findings for Medscape Medical News, Carla Marienfeld, MD, University of California, San Diego, said, "I think this is a very critical issue that is underconsidered, both in treatment and in public health interventions.
"It's also interesting because it shifts the narrative away from putting responsibility on the individuals who are now self-medicating as a result of trauma with alcohol or other substances to other factors or individuals that are influencing the use of drugs," Marienfeld said.
"The results from this survey and the resources and tool kit that Dr Warshaw mentions can be used therapeutically to help victims of domestic violence understand their relationship with substances and potentially how healing from the domestic violence can free them from their addictions."
The National Center on Domestic Violence, Trauma and Mental Health is supported by a grant from the Administration on Children, Youth, and Families, Family and Youth Services Bureau, US Department of Health and Human Services. Warshaw and Marienfeld report no relevant financial relationships.
American Academy of Addiction Psychiatry (AAAP) 30th Annual Meeting. Paper A 5. Presented December 06, 2019.
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Cite this: Forced Drug Abuse a Hidden but 'Disturbingly Common' Part of Domestic Violence - Medscape - Dec 09, 2019.