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Official websites use. Share sensitive information only on official, secure websites. Both authors assume full responsibility for the content. Address correspondence to: Dr. Wilson Compton, Executive Blvd. The roots of the remarkably lethal U. Failures of the healthcare system——including lack of both training in pain management and caution in using an addictive class of medications——precipitated the rise in opioid misuse and addiction over the past two decades, but a wider range of social and economic forces has helped perpetuate the crisis and altered its character. Interventions addressing multiple components are needed, including solutions that account for behaviors of all vectors associated with the crisis. For prescription opioids, the vectors include clinicians and pharmaceutical-related companies involved in marketing, prescribing, distributing, and dispensing opioid medications; for illicit opioids, they include drug manufacturing and distribution networks. Attending to the vectors of opioids, while simultaneously implementing a full range of public heath, clinical, law enforcement and other approaches to ending the opioid crisis, may help to improve public health outcomes. The opioid crisis that has unfolded and evolved in the U. The roots of the opioid crisis are complex and inextricably entangled with the healthcare system, especially in relation to treatment of the serious health problem of pain management. The classic epidemiologic host—agent—environment triad can be augmented with the addition of the vector as a way toemphasize the importance of the purveyors of opioids licit and illicit in the current opioid crisis and to elucidate a full host—agent—vector—environment model of the epidemiology of, and inform the response to, the opioid crisis. The U. Although involving compounds that are closely similar in their pharmacologic properties, the opioid crisis in the United States is really two sets of intertwined issues: misuse of and addiction to prescription opioid analgesics, which predominated in the first decade of the crisis, and, more recently, use of and addiction to illicit opioids Fig. Within the rubric of illicit opioid use, a further distinction can be drawn between the resurgent use of heroin and the problem of both deliberate and unintentional use of even more potent synthetic opioid drugs namely, illicitly made fentanyl and its analogs. A rapid rise in deaths involving these synthetic opioids, beginning in , marked a third wave of the opioid crisis. Opioid-related Overdose Death in the U. In addition to the significant rise in mortality, opioid use has been associated with increasing morbidity. Incidence of NAS among U. Increasing transmission of infectious diseases associated with injection drug use, in particular increasing rates of opioid injection 9 , have been another consequence of the opioid crisis. Hepatitis C virus infections increased in the United States over the last decade, with particularly large increases in states heavily impacted by the opioid crisis. Classic epidemiology models focus on three key components that can help to explain the spread and impact of diseases or conditions: host, agent, and environment HAE components. Within the host component are individual susceptibility factors, including genetic background and specific behaviors that may put an individual at risk. The agent is the external causal factor i. The environment encompasses factors external to the agent and host that can influence susceptibility, including both the physical and social domains. An important component of all aspects of opioid epidemiology are market forces, that is, the economic incentives that inspire both illicit sellers and licit providers of opioids and influence substance use patterns through their behaviors. As has been described in tobacco epidemiology, 15 but not previously explicated for the opioid crisis, the vector emphasizes the active role of product purveyors. These vectors contribute to and influence both the extent and spread of the opioid crisis, and must be considered when planning responses. As illustrated in Figure 2 , this host—agent—vector—environment HAVE model is incorporated into the descriptions below. Adding the vector component to the epidemiologic model provides a more complete systems approach to understanding the opioid crisis than the HAE model, and explicating the bidirectional relationships among the HAVE components illustrates this point. Within the bidirectional host and vector components, for example, opioid users respond to the vector whether illicit drug dealers or physicians writing prescriptions by adjusting their sources of supply. Conversely, as opioid users pursue new avenues for their drugs, the vectors of opioids both prescribers and illicit drug dealers shift their behaviors, such that physicians may limit their prescribing and drug dealers may target a wider group of potential customers. Each of the pairs of HAVE components can be seen as contributing similarly to a complex web of causation, with bidirectional influences across six component pairs: host and agent, host and environment, host and vector, agent and environment, agent and vector, environment and vector. In , Opioid misuse and OUD have always been uncommon among adolescents, and that remains the case: in , 0. Young adults age 18—25 , however, have the highest rates of opioid misuse and opioid use disorders, with 1. Opioid misuse and opioid use disorder has a strong genetic component. Some socioeconomic factors such as poverty are correlated with opioid misuse. Mental illness, especially mood disorders, often co-occur with OUD. According to data from the Nationwide Emergency Department Sample for the years —, just over half of adult ED visits for opioid poisonings As with mental illness, opioid misuse and OUD often co-occur with other substance use disorders. OUD is also highly comorbid with pain. Prescription opioids and illicit opioids such as heroin and fentanyl are pharmacologically quite similar. They interact with endogenous opioid systems that regulate several functions via three types of G protein—coupled receptors: mu, delta, and kappa. Principally, they are potent agonists at the mu receptor. The close coupling of these two effects underlies the inherent risks of misuse of opioids when used for analgesia. Mu-opioid receptors are also concentrated in brainstem areas controlling respiration, which accounts for the life-threatening danger of overdose, as mu-opioid agonists suppress respiration. It was originally thought that prescription opioid misuse and addiction was overwhelmingly confined to those using diverted prescription opioids; it was even believed that pain had a protective effect against becoming addicted to these medications. But while it remains true that only a minority of patients with pain who receive opioids become addicted, as the volume of produced and available opioids increased in the United States, so did rates of treatment admissions for prescription opioid misuse. Methadone prescribed for pain has proven particularly dangerous from an overdose standpoint. But its long half-life, slow onset of action, and complicated pharmacokinetics and pharmacodynamics make it difficult to manage medically, as well as make it particularly prone to overdose. In addition to an increase in the absolute number of prescription of opioids during the s and s, how opioids were prescribed began to change, with opioids increasingly prescribed at higher doses, for longer durations, and in combination with benzodiazepines——all now well-recognized risk factors for overdose. Illicitly made synthetic opioids generally related to fentanyl and similar compounds comprise a newer agent in the opioid crisis, as highlighted by the marked increase in overdose deaths involving these synthetic opioids, beginning in Prescription drug misuse is very different from other illicit drug use issues because it is intricately intertwined with both the healthcare system and a parallel health issue affecting many Americans: pain. Physicians and other healthcare providers had learned from historical experience of the dangerous addictiveness of opioid drugs, and for decades were therefore reluctant to use them to treat most pain conditions. Beginning in the s, however, there were calls from some physicians and patient advocacy groups that not enough was being done to treat pain, both in cancer and palliative-care patients, and even more generally. A now notorious one-paragraph letter in the New England Journal of Medicine in stated that among a large sample of hospitalized patients who had been given opioids, only four developed addiction. On the basis of these studies, pain advocacy organizations and some in the medical community began to seek state-based regulatory changes to reverse the perceived underuse of opioids to address chronic, non-cancer pain. These clinical practice and regulatory changes coincided with business decisions that fueled a marked increase in opioid prescribing and subsequent public health harms. The marketing of OxyContin was particularly noteworthy: it included high-levels of targeted outreach to primary care physicians, outreach at national meetings, incentivized sales, and even illegal sales practices, all of which fueled multi-billion dollar medication sales increases starting in the s. And unknown at the time, these new populations of persons with addiction to prescription-type opioid were primed for even greater dependence and crisis from the coming influx of heroin and illicit fentanyl in subsequent years. Shifting attitudes, marketing practices, and policies related to assessing pain occurred in the context of a medical education system that did not adequately train healthcare providers to provide state of the art treatments for pain that fully incorporated concerns about opioid misuse and addiction. According to a study, many medical schools at that time offered less than 5 hours of training in pain management to their students, with some offering no training. Whereas about a third of people who misuse prescription opioids get them from their own prescription, more than half report obtaining them from family or friends who have prescriptions. The s and s also saw the development of rogue pain clinics sometimes called pill mills where opioids were prescribed and dispensed in large quantities but with few clinical indications. While the evidence is mixed on their overall effectiveness, policy requirements for clinicians to use and integrate a PDMP into health delivery appear to be associated with reduced overdose risks. Marketing of heroin has also shifted with changes in both the supply countries i. However, in recent years, the influx of historically high-purity and low-cost heroin in urban, suburban, and rural areas of the U. Those with onset of opioid use since are again increasingly likely to report that heroin was their first opioid of misuse. While the increased difficulty of obtaining diverted prescription opioids among people addicted to them appears to have contributed to expanded heroin use, market forces related to illicit drug trafficking have also played an enormous role. Recently, intercepted heroin made from poppies grown in Mexico has been shown to be of higher purity than heroin samples available previously. Being synthesized in a lab makes fentanyl and its analogues relatively inexpensive to make and results in a substantially higher profit margin than heroin. The high level of potency also helps to explain their lethality. A key question is, how much do people who use drugs actively seek fentanyl versus how much is surreptiously added to the drug supply? While unintentional ingestion is certainly common, it appears that fentanyl is actively sought by some individuals who use drugs, and the high potency, as indicated by overdoses, may encourage use of particular drug supplies. Given how rapidly, and with such devastating effects, synthetic opioids have overtaken heroin and prescription-type opioids, it is imperative that the public health community remain vigilant to market developments. The cost efficiencies and small volume of synthetic opioid products will likely continue to drive changes in drug use behavior and outcomes. The latest data from the U. Drug Enforcement Administration DEA indicate an expansion and westward shift of fentanyl and fenantly analogs in recent years; 83 however, it remains to be seen how completely synthetic opioids will supplant other opioids in the illicit markets over the next few years. At a minimum, strengthening partnerships between law enforcement and public health may provide important data to inform health interventions. There is significant geographic variability in the rates of drug overdose see Fig. This variation is associated with a range of demographic and structural factors including healthcare infrastructure, opioid prescribing, treatment availability, availability of naloxone, and penetration by drug traffickers. For example, while there were 8. For example, the proliferation of illicitly-made synthetic opioids has disproportionately impacted states in the eastern part of the U. Since , the majority of illicitly-made fentanyl and fentanyl analogs have been concentrated in states east of the Mississippi, where powder heroin, the predominate form of heroin, is more amendable to mixing with powder fentanyl than is black tar heroin, which is historically found in the western U. Estimated age-adjusted death rates per , for drug poisoning overdose by county in the U. Optimal public health efforts to reduce the number of deaths from opioid overdoses require approaching the problem from a range of angles, including prevention, treatment, and harm reduction. Considering the role of the vector in the opioid crisis is also important. Given the structural impact of the health care system, addressing how pain and addiction are managed and treated is key. Anticipating how the purveyors of both licit and illicit substances will respond and adapt to the public health response, and remaining nimble as the response evolves, are also essential. The public health response should be comprehensive to address both the upstream drivers and downstream consequences of opioid misuse, use disorder, and overdose, as well as prevent a shift to use of other substances. The response should also be balanced to ensure that efforts to constrain the prescribing of opioids are implemented in tandem with both appropriate tapering protocols for patients discontinuing use of opioids and expanded access to non-opioid pain treatments. It has been well-documented that expanded access to medications for opioid use disorder is associated with reduced overdose mortality, among other public health benefits. A comprehensive discussion of all the public health interventions required to address the opioid crisis are beyond the scope of this review. Nevertheless, currently available evidence suggests the importance of five critical strategies: 1 healthcare provider education, training, and guidance, including deployment of clinical tools such as prescription drug monitoring programs to monitor patient controlled substance prescriptions; 55 , 64 — 66 , 93 — 96 2 primary prevention of substance use, including opioid misuse; 97 , 98 3 expansion of medication treatment for opioid use disorders; 92 , 99 — 4 access to, and use of, naloxone; — and 5 implementation and scaling of comprehensive syringe services programs and other harm reduction programs, as part of an overall effort to minimize negative health outcomes associated with opioid use and use disorder. Finally, ensuring that the overall response is attentive to the vectors of licit and illicit opioids, especially the illicit drug dealers who are outside the reach of mainstream public health interventions, is an essential component of a comprehensive plan. Thus, the public health response must be implemented in tandem with public safety and supply reduction efforts that aim to interdict and reduce the availability of illicit substances, apply appropriate, evidence-based policing and criminal justice interventions, including the provision of evidence-based treatment to individuals with opioid use disorder within the criminal justice system, and bring to scale innovative public health and public safety partnerships that improve utilization of effective opioid prevention and response strategies. Although failures of the healthcare system, such as lack of training in pain management and of caution in using a class of medications known to be addictive, precipitated the rise in opioid misuse and addiction over the past two decades, a wider range of social and economic forces has helped perpetuate the crisis and has altered its character, including multiple drug crises involving addictive compounds that are closely related chemically but require different yet coordinated responses. The classic epidemiologic host—agent—environment triad can be augmented with the addition of the vector as a way to emphasize the importance of the purveyors of opioids licit and illicit in the current opioid crisis and to elucidate a full host—agent—vector—environment model of the epidemiology of, and inform the response to, the opioid crisis. Interventions addressing multiple components are needed, including solutions that account for behaviors of vectors of all types. For prescription opioids, vectors include clinicians and pharmaceutical-related companies involved in marketing, prescribing, distributing and dispensing opioid medications; for illicit opioids, they include illicit drug manufacturing and distribution networks. Attending to all vectors of opioids while simultaneously implementing the full range of public heath, clinical, law enforcement and other approaches to the opioid crisis will likely help to improve public health outcomes. The findings and conclusions of this study are those of the authors and do not necessarily reflect the views of the National Institute on Drug Abuse of the National Institutes of Health, the Centers for Disease Control and Prevention or the U. Department of Health and Human Services. As a library, NLM provides access to scientific literature. Ann N Y Acad Sci. Epidemiology of the U. Find articles by Wilson M Compton. Find articles by Christopher M Jones. Author contributions W. Issue date Sep. PMC Copyright notice. Open in a new tab. Disclaimers The findings and conclusions of this study are those of the authors and do not necessarily reflect the views of the National Institute on Drug Abuse of the National Institutes of Health, the Centers for Disease Control and Prevention or the U. Competing Interests W. Similar articles. Add to Collections. Create a new collection. Add to an existing collection. Choose a collection Unable to load your collection due to an error Please try again. Add Cancel.

Epidemiology of the U.S. opioid crisis: the importance of the vector

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This article elucidates the dynamics that occur in relationships where there have been both substance use and domestic abuse. It draws interpretively on in-depth qualitative interviews with male perpetrators and their current and former partners. The criminological implications of the competing models of change deployed in drug treatment and domestic violence intervention are discussed alongside the policy and practice challenges entailed in reconciling them within intervention contexts where specialist service provision has been scaled back and victims navigate pressures to stay with perpetrators while they undergo treatment alongside the threat of sanction should they seek protection from the police and courts. Explanatory Note Clause 3: It is proposed that compliance with such orders will be secured in part through electronic monitoring. The Bill is informed by a prolonged consultation in which over 3, responses were received by government and expert opinion—primarily from organizations representing victims and survivors of domestic abuse and stalking—was submitted to two Home Affairs Committees House of Commons, Cross-party support for the Bill was secured: as politicians registered the volume of domestic abuse cases raised with them by constituents; amidst news that the daughter of an MP had committed suicide following a relationship in which she suffered psychological—but not physical—torment that caused her to fear that she was mentally ill Elgot, ; and during a campaign by David Challen to enable his mother to appeal her conviction for murdering his coercively controlling father Moore, But this Bill was conceived within a more nuanced policy agenda than its predecessors. This article responds to this call to redress the dynamics of power that occur in relationships where substance use and domestic abuse co-occur. We contribute to such an understanding through the presentation of three couple dyads—each comprising a male perpetrator and his female partner—interviewed in-depth for the UK National Institute for Health Research funded Advancing theory and treatment approaches for males in substance use treatment who perpetrate intimate partner violence ADVANCE programme 1. Our conclusion returns to the challenges the Domestic Abuse Bill poses to policy, practice and criminological theorizing. Evidence for the relationship between domestic abuse and drug and alcohol intoxication is plentiful in crime surveys but tends to focus, peculiarly, on the behaviour of victims more often than offenders. The international evidence reveals that men, but not women, tend to perpetrate more severe assaults when they have been drinking Graham et al. Women are more vulnerable to assault when they too are intoxicated, but this is at least partly because those living with abusers are less diligent at pursuing safety strategies when they have been drinking Iverson et al. Substance use features in around half of all UK domestic homicides. Since , substance use has been detected among domestic homicide perpetrators more than four times as often as it has among those killed by them Home Office, In sum, the relationship between substance use and domestic abuse is not straightforward. Moreover, Different substances have different pharmacological properties. Cocaine consumption can induce similar reactions. Like cannabinoids and opiates—the effects of which are rarely studied in the context of aggression or violence—cocaine can also alleviate anxiety and exacerbate underlying problems with depression, paranoia and hallucinations Sacks et al. Consequently, regular use of such drugs, like the consumption of excessive alcohol, can impinge upon mental well-being and intimacy, generating indirect and belated relationships between victimization and substance use that extend far beyond periods of intoxication. Feminist scholarship on domestic abuse has tended not to engage with the pharmacological impacts of substance use and has focussed instead on how some abusive men retain power over women by attributing their violence to intoxication, by insisting that their drinking caused them to act out of character, or by denying any memory of assaults perpetrated when intoxicated Hearn, ; MacKay, Evaluations of interventions for perpetrators have thus needed to be alert to the ways in which substance use is invoked to minimize violence. His analyses reveal that some victims do self-medicate to manage the depression the daily anticipation of violence engenders and that some perpetrators control victims by increasing their dependence on substances before restricting their access to them. Finally, Stark highlights that some women who have been terrorized over many years take matters into their own hands after the law has failed to protect them, mounting grievous attacks on perpetrators when they are too intoxicated to retaliate. This is despite clinical evidence suggesting that drug use and violence co-occur most among men with diagnosed mental health issues, poor concentration and problems understanding and remembering their pasts Sacks et al. Answers to this question can be found in the few qualitative studies that explore how drugs and alcohol feature in the relationships of couples living with domestic abuse. These reveal that some perpetrators pose greater risks to their partners, not when they are high, but when they are irritable, withdrawing or are struggling to finance alcohol or drug purchases Gilchrist et al. Follow-up interviews with 20 couples where alcohol consumption was noted by the police revealed that, although drunkenness and its expense were the source of many arguments that led to violence, social drinking, especially at parties, was also what held some relationships together. Afterwards, some couples reconciled on the basis that it was the alcohol that caused the conflict. Men who had caused injuries when intoxicated often claimed they could only recall feeling hurt—sometimes in ways that reminded them of painful experiences in their pasts—by female partners who criticized them or acted aggressively towards them and not the assaults they themselves had perpetrated. Motz depicts the emotionally impoverished lives of abusive men with whom some drug-using women cohabit, many of whom feared abandonment because of experiences of abuse, neglect or institutional care. Some women described engaging in prostitution to raise money for drugs as evidence of their love and care for male partners. When the women subsequently refused to raise funds in this way or sought support from professionals to reduce their own drug use, some male perpetrators threatened further violence whereas others encouraged them to relapse back onto heroin or crack, thus entrapping stigmatized and socially isolated women in relationships with them. In what follows, we expand the argument for a more relationally sensitive analysis of the dynamics of power that pertain in the lives of couples where domestic abuse towards a partner occurs alongside substance use. We seek to illustrate these points by drawing on dyad interviews—with male perpetrators in treatment for substance use problems together with their current and former female partners—undertaken for the ADVANCE programme. The ADVANCE programme seeks to develop and test an integrated intimate partner violence and substance use group intervention that will reduce intimate partner abuse perpetrated by men receiving substance misuse treatment. This involved interviewing male domestic abuse perpetrators receiving treatment for substance use and their current or former partners about their relationships and support needs. Adult men were recruited from six community-based substance use treatment services in London and the West Midlands. Seventy men were screened for lifetime domestic abuse against a partner. Men who currently had court orders preventing contact with their ex partners were excluded. Forty-seven of the 70 men screened were eligible, and 37 of these 47 men were then interviewed. Male interviewees were asked to provide contact details of their current or former female partners, and in 14 cases these women were interviewed. All participants were advised that there were limits to the confidentiality that could be afforded where unaddressed risks of harm and safeguarding issues were disclosed. Women and men were always interviewed by different researchers to ensure no information was inadvertently shared between participants. Interviews were undertaken using reflective techniques derived from the Free Association Narrative Interview Method Hollway and Jefferson, , with participants being supported through active listening to tell the stories of their drug use, relationships, domestic abuse and intervention experiences. Digital recordings of the interviews were transcribed verbatim and transcriptions were checked twice for errors. Timelines were created to track the sequence of events through the life of each participant. In terms of their drug use, the 14 men who were interviewed with their partners appeared to be broadly comparable with the other 23 whose partners were not interviewed Table 1. Nine out of the 14 were also heavy drinkers. Five of the 14 men also described medical or psychological diagnosis consistent with emotional dysphoria. Eight males disclosed perpetrating violence that was extra-familial in addition to their abuse of partners. Contact with children had, at some point or other, been restricted for all the men in the study. Given the high degree of similarity among the men on key variables, we explored if more meaningful distinctions could be drawn by distinguishing the dyads in terms of whether victims had ever used drugs and, if they had, whether they were desisting from substance use or still using. Only four of the women described themselves as substance dependent at the time of the interviews. Five had never been substance dependent, and another five were desisting from substance use, either having become completely abstinent from using or having only had temporary relapses. A three-fold distinction could thus be drawn across the dyads that revealed some important variations in terms of how domestic abuse and substance use manifested themselves. Within the sample, there were five couples where the female partner had never been substance dependent, though all the women interviewed drank alcohol socially, and one smoked cannabis occasionally. Women in this group had almost no involvement in crime. Four of these women had never been separated from their children, but one woman had children who had been required to live with their grandfather as she would not leave her abusive partner. Within the sample, there were five couples where the female partner had abstained from using drugs or alcohol, having previously been substance dependent. None of these women had criminal convictions. The stories these desisting women told tended to be of intimacy lost. Sharing feelings and traumas that motivated drug use, and about what made it difficult to give up, had generated understanding and closeness when they had first met their partners. Conflicts had then developed when the men resumed drug use or drinking whereas the women were trying to reduce their own or abstain. Only two of the women in this group had children of their own. In both cases, these women had raised their own children, but with some intermittent professional oversight. Within the sample, there were four couples where both the male perpetrator and the female victim were both currently substance dependent. All the women in this group used crack cocaine and heroin to varying degrees. Though they sometimes mentioned love, they often explained their persistence with relationships that had become abusive in terms of daily needs for protection, somewhere to live and the sharing of drugs. The women in this group had much more frequent and entrenched patterns of criminal involvement than the other 10 in the sample. Their criminal involvement activities included shoplifting, petty frauds and prostitution to finance their drug use, typically with encouragement from male partners who relied, to some extent, upon the income the women generated. All four women in this group had been separated from their children when these children were young, though two women had re-established relationships with their children in adulthood. In what follows, we present one couple from each of these groups to further illustrate the different power dynamics that can pertain in relationships where domestic abuse and substance use co-occur. Italics are used to highlight points where the participants emphasized a relationship between substance use and domestic abuse. Rhian recalled that Wayne first assaulted her within a couple of months of moving in. After a drink with friends and not knowing that she was already pregnant, Rhian felt ill and went to bed. Wayne provided a detailed account of the emptiness he felt. After a nurse overheard Wayne discussing drugs on his phone during one of the few antenatal appointments he attended, Rhian took the opportunity to ask him what it was about because she was concerned that social services would see a child protection risk for her baby. Sometimes Wayne would speed off, with their baby in the back of the car, in a hurry to buy drugs. The violence only ceased, Rhian said, when Wayne called the police on himself after pinning her down and grabbing her by the neck. Mitchel early fifties and June mid-forties were in a relationship for over 15 years. As a child, June was repeatedly coerced into having sex by a man who threatened to report her to social services for caring for her siblings while her mother received hospital treatment. When she became pregnant, she weaned herself off it but relapsed when her mother accused her of inviting the sexual abuse she was subjected to as a child. Mitchel made no mention of these incidents but said June had become domineering about domestic matters when he returned from university. The police attended but arrested neither of them as they had both been drinking. After a period in hospital, June said June contacted a drugs and alcohol dependency team who put her on a methadone programme, but Mitchel started taking the methadone because he feared he would lose the house and his children if June recovered. Joe mid-thirties and Kate late twenties had been together for six years. Kate had been sexually assaulted both as a child and as a teenager and was estranged from her family. Joe, whose parents were both deceased, was sexually abused while in care and was estranged from his siblings. He said he worried that Kate would be raped or killed by men she had clipped and that he had lost teeth defending her from men she had tricked. While Joe was in prison for this assault, Kate twice attempted suicide. In this article, we have presented three relationship scenarios where domestic abuse pertained alongside drug or alcohol dependency. Wayne, Mitchel and Joe all described discrete, regrettable and unplanned assaults that derived from everyday conflicts over alcohol and drug use, financial pressures, sexual jealousies and domestic chores: conflicts that were sometimes accentuated by being intoxicated. Nevertheless, the stories these men told suggested that their need to control became increasingly acute when their relationships were in crisis, when they had secrets to keep, when they felt dependent on drugs or alcohol, were afraid of losing their minds, their partners and their children, when money was scarce, and when homelessness and criminalization were distinct possibilities. Despite their unhappiness, these men, like their partners, often lacked the emotional strength and economic resources required to separate Walby and Towers, By contrast, Rhian, June and Kate, described steadily accumulating patterns of abuse, forgiven initially as promises of fresh starts, either in new places or after drug treatment, were made. Hence, the reasons these women stayed were complexly configured around drug and alcohol use. Then, as someone with little experience of either drugs or relationships, Rhian was persuaded to give Wayne another chance while he sought drug treatment, assuming mistakenly that this would redress his violence. June, by contrast, had some empathy with Mitchel, having relapsed with heroin herself and recognizing that her own drinking contributed to their arguments. June had been persuaded that moving might facilitate a fresh start, without drug use. However, when June sought opioid substitution treatment for herself, Mitchel found a new way of controlling her, diminishing her capacity to leave by controlling her access to her prescription and then trying to administer an overdose. The challenges for Kate were different again. She had a long history of heavy alcohol consumption and illicit drug use, the latter of which Joe had joined in with, compounding their mutual dependence on shoplifting and pseudo-sex work to maintain their supplies. Joe construed his heroin use as an attempt to empathize with Kate, though it appeared that he persisted with drug treatment partly because it legitimized his management of her drug use. For the women in these relationships, criminal justice intervention was often greeted with trepidation, for it rarely provided the protection it promised. For June and Kate, the pains of child abuse, mental health problems and bereavement were partly responsible for the solace they had sought in alcohol and heroin consumption, as well as in their relationships with men. However, as their drug and alcohol usage became complicated by domestic abuse, a range of different strategies were pursued by each couple, typically to avoid attracting the attention of social services or the police. These dynamics were compounded as drinking and drug use generated financial pressures, which intensified conflicts that left the women, as well as some of the men, feeling that their partners regarded sustaining their substance use as more important than their relationship, avoiding criminalization and social services intervention, and the threats posed by those from whom money and drugs had been borrowed or defrauded. Evidently, some abusive men tell highly convoluted stories to exonerate themselves. But some women who are the primary victims in such relationships do not and cannot always tell the whole truth either, not only because they fear further violence and abuse but also because of the stigma of their own drinking and drug use, the fear of child protection proceedings being instigated and the risk of being incriminated by perpetrators they have hit in self-defence or retaliated against Wolf et al. Like many of the men in the ADVANCE programme study, the perpetrators we have depicted here dealt with feelings of trauma and grief from their pasts through drug use and by scaring their partners in ways that the women experienced as acutely controlling. While frequently terrifying, such behaviour was not only instrumental and controlling but also expressive of how painful some aspects of their pasts were and how unwilling they were to concede their dependency on both substances and partners who provided care, funds, a place to live and the support needed to maintain precarious relationships with children. Similar experiences of child abuse, mental health problems and drug dependency were sometimes part of the story of intimacy that held these couples together despite grievous domestic abuse. Then, when the risk of criminalization or estrangement presented, men who were coercively controlling sometimes used such prehistories against their partners by threatening to expose them for raising children in contexts that were unsafe. It has, to some extent, been be amplified by the advent of gender-neutral policy, which recognizes that men can be victims too, alongside incident-focussed approaches to policing that direct attention to what has just happened—such as a man being hit—rather than the history of the relationship—such as a woman being terrified or controlled by the same man over a prolonged period Walklate et al. The Domestic Abuse Bill attempts to counter this risk by prohibiting perpetrators from cross-examining victims in the family courts and providing greater recognition of the impact of the ways in which economic abuse makes it harder for many victims to leave. But compelling alcohol and drug-using perpetrators to receive treatment may introduce unforeseen possibilities for coercive use of the law. Others will stay under the misapprehension that the domestic abuse will cease once treatment for substance use begins. This is an unlikely outcome, though intervention is nonetheless worthwhile. There is tentative evidence to suggest that reducing drinking among perpetrators can diminish resort to violence Wilson et al. But, although treatment interventions can reduce the harms of substance use, where drug and alcohol use and domestic abuse co-occur, treatment needs to be part of a range of measures that include support in changes in thinking and modes of relating, securing the housing and economic resources couples need to be able to contemplate living apart, the support and empowerment of survivors, the safeguarding of children and professional help with mental health problems. These skilled forms of intervention are critical to deescalating the dynamics that sustain substance use in the lives of people enduring the worst forms of domestic abuse but are often in short supply. One danger with compelling drug or alcohol treatment is that it will place clinicians and health practitioners in the ethically compromising position of having to report those who relapse, together with those whose prescriptions have proved insufficient, or who have decided that they would be better trying to reduce their substance use gradually, to the courts where they may face further criminalization Seddon, ; Werb et al. Hence, acknowledgement of complexities in the power dynamics of domestic abuse that co-occurs with drug, alcohol and mental health problems raises acute challenges, not only for the delivery of policy that attempts to reconcile safety, justice and rehabilitation but also for academics who have framed the problem of domestic abuse primarily as one of either gender or psychology. Not only do criminologists need to reconceptualize domestic abuse more dynamically but they must also ask why some men choose to secure control in coercive ways when so many other aspects of their lives appear out of control. There is a need to recognize how the interdependencies—including the prospect of economic abuse—involved in intimate relationships are intensified by poverty, stigma, co-dependency, child abuse and neglect, poor mental health and the fear of police and social services intervention. In theory and in practice, we must ensure that shorthand explanations derivative of personality disorders do not obscure what can be learnt from the more complex descriptions both survivors and perpetrators can offer of their relationships. Policymakers need also to ensure that evaluations of treatment options for substance-using perpetrators extend beyond the longstanding fixation with acquisitive crime to include measures that take stock of their impact on children and partners, whether current and former, and to recognize that establishing effective practice will require the reestablishment of expertize and service provision that is increasingly scarce. Benitez , B. Google Scholar. Brandon , M. Broyles , L. Dobash , R. Google Preview. Douglas , H. Elgot , J. Felson , R. Gadd , D. Gilbert , L. Gilchrist , G. Gossop , M. Graham , K. Hearn , J. Heidensohn , F. Rafter and F. Heidensohn , eds. Open University Press. HM Government. Hollway , W. Holtzworth-Munroe , A. Home Office. House of Commons Home Affairs Committee. Scandinavian University Press. Iverson , K. Johnson , M. New University Press. Kelly , L. Leonard , K. MacArthur , G. MacKay , F. Moore , A. Motz , A. Reno , J. Robinson , A. Cardiff University. Sacks , S. Seddon , T. Stark , E. Oxford University Press. Strang , J. Tolmie , J. Vigurs , C. Walby , S. Walklate , S. Werb , D. Wilson , I. Wolf , M. Hobart , M. Zinberg , N. Yale University Press. Oxford University Press is a department of the University of Oxford. It furthers the University's objective of excellence in research, scholarship, and education by publishing worldwide. Sign In or Create an Account. Sign in through your institution. Advanced Search. Search Menu. Article Navigation. Close mobile search navigation Article Navigation. Volume Article Contents Abstract. Correlations and typologies. Complex interdependencies. Group 1 exemplar. Victim was never substance dependent. Group 2 exemplar. Victim was desisting from substance use. Group 3 exemplar. Victim was substance dependent. Discussion and conclusion. Journal Article. David Gadd , David Gadd. Oxford Academic. Juliet Henderson. Polly Radcliffe. Danielle Stephens-Lewis. Centre for Violence Prevention, University of Worcester. Amy Johnson. Gail Gilchrist. Select Format Select format. Permissions Icon Permissions. Abstract This article elucidates the dynamics that occur in relationships where there have been both substance use and domestic abuse. Table 1 Open in new tab. Self-reported substance use within the sample. Number who said they had regularly used heroin. Number who said they had regularly used crack cocaine or powder cocaine. Number who said they had regularly used more than one illicit substance. Number who said their alcohol consumption had been high, heavy or problematic. Substance use among the 37 male perpetrators who undertook in-depth interviews 31 26 34 24 Substance use among the 14 male perpetrators whose partners were also interviewed 13 11 13 9 Substance use among the 14 female partners 7 5 6 6. Google Scholar PubMed. Google Scholar Crossref. Search ADS. Download all slides. Views 40, More metrics information. Total Views 40, Email alerts Article activity alert. Advance article alerts. New issue alert. Receive exclusive offers and updates from Oxford Academic. Citing articles via Web of Science Coercive Control. Barlow and S. More from Oxford Academic. Criminology and Criminal Justice. Social Sciences. Authoring Open access Purchasing Institutional account management Rights and permissions. Get help with access Accessibility Contact us Advertising Media enquiries.

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